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ICMH

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Series

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(Monographs)

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©1996

-^m

/ti>>i''/ ;r^A;- ■, V ■•'^A^',, ^i■:■^

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Medical Library

McGill University

Montreal
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1

2

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1 2 3

4 5 6

'^'sam, t^jsr msd

■ i^l&'SM^miKSSkVL^^^

MICROCOPY RESOLUTION TIST CHART

(ANSI ond ISO TEST CHART No 2)

^ APPLIED IIVUGE

1655

East

Mom 51

eet

Rochester,

Ne* To

14609

USA

(716)

«a2

- 0300

- Pho

ne

(''6)

288

- 59S9

- re

f'^w-^r^'^

THE ACUTE ABDOMEN

].',„. i._Stniiigiiliitioii (if Intestine by Fibrous linnil (1; : 37!», St. Thomas

Hospital Museum.

THE ACUTE ABDOMEN

WILLIAM HENRY BATTLE,

Senior Surgeon li> Si. Thnma^\ Hospital-

i'oiiihrly Jt'iiil Leitiiiir oi Syitiiii.itw .S'//):.v) i. ,(«,(' fi; riti.tu,il Sii>::ii\
/.) .S7, 7Vi,im.(j's Ilispltill Mldu.il SJi.-.il , Siin.;;'!! /,- til, h'-'V.il I'n;
Ilvsf'iliil: Assiitjut Surgeon !•> the luist /..•/(./■•/i fl^-./'it.il loi Chriiii't ;
Hiiiiteniiii Pr.fesior, Koyal C-'lUi;, t^f Siin;eoiis : Ouili t.< tli,- MrJicit
Sucnly i:f London, etc. : Joii .Intlior ^:.-ilk Mi Conhi \ of tiic Siii^ e.i!
iJiseascs of the \'ennifoiiii .{/•(•eiidn lIiiJ then Coiiir:u\ilii'iii i -'»<i : I i. i7i-.

SECOND EDITION. ENLARGED AND ILLUSTRATED

f

■v

'ili

THE MACMILLAX COMPAXV OF CANADA, LTD.,

TORONTO

1914

r" .m.

IMiKKACK

TiiK lii«.t I'llitioii ot Lecture^ on ' Tlic Acutf .\1» lumcii "
liaviii}.' hccHmc f:diiin>tc(l some iiKiiitli- a^io. I wa-^ rci|in -tcil

hy th<* |)iil»li>^lu IS to write a s ml tili'inii. with mkIi alterations

anil aililitions as nii^ht secin advisable. 'I'lu- eotitiiiiieil aiUanci-
of oiir kiiowleiljic of the aente eoiiditions wliieli may arise iu
the alxloim n has necessitat'd an increase in size of the volume.
wliiUt it lias appeared desirable to a Id the accounts of many
ea^c> an I illu-iratioiis with the view of more thoroughly
elucidat iiisi the subject. So many acute ab 'ominal diseases
have prosed curable by oprrat'on. w hiii it !■• performed early,
that I hope my rea lers will not consider the >ubject unduly
ma<;nitied consider'n^ its impoi'tance in modern practice. 'I'he
treatment of ,he acute ab;!omi 'i (includini: th.il of lesions the
result of traumatism) demands an ai |uaintancc with the
.^urjiical part of the subject which eainiot always be obtained
in text books on sur>.ery. In addition, it may be added that
in ord' '■ to l)f of uencral application the metho.ls described
should bi- as siiuple as po>sible. so thai no practitioner need
t -ar to make an attempt * i save a threatened life l)ccause he
his no^ >ome particuhir clamp. l)o))bin or brand of catgut in
hi^. possession. Silk is still recommended, because it is stron<^
an I can lie 'rusted. .Moreover, ii is easily >tei'ilised by boiling,
even in a cottage.

Tile principal additions to the ])resent volume, wliicli is
divided into sections, are t >se on the planning of ab lominal
incisions and injuries to ihe abdomen, external ami internal,
iiuUuling most of the subject-nii ter of the Oration given
Ix'fore the Medical Society of London in !(tlu. There is a
special section on the after effects of ab. lominal injuries.
An endi'avour has been made to iliffercntiate clinically some

\ I

I'UKF.v »•:

nl I lit- sariftu- ot piritiinitH (It'iMndcnt im i!if<Tti<iii nt tlic
ix'iiioiii'iiiii thruimli ih" hl.Miil ^triiim ; wliiixt in ail<liiior>
Ihrr.' arc Mctioii- .>ii |MHnratii)i»> *' tulxn iiliiii> iihi-ratioii ul
tlir ml -till'' . |M iforatitms ot (livfrticulu nt tin- larKr Ituwcl ;
iiitia|>!iit(iM(iil al»-ii>sc« cnmcali'il ahscissr^ : sijrmoitlitiH ;
miporiaiil «liaiiu<-' cniiiiilitatiiin tiimoinN .it flu utcr'i- and
tiimniir^ nt llif nvaiio : and toryion of the onu iituiii. In
I'art \ II. an accnunt i- ):ivtn ot divtrticuluni ot tin- ( v>lit duct
ot conjicnital origin. Since I commenced my la>k a hook lias
a|i|>rar.;l hy my ••olH'a«Uf!<. Messrs. .\dam> ami ('a^sjdy. whicli
cover- the •;•... le field to a jireat extt-nt. It is an excellent one.
and will meet with a wide accept anec .\> this hook is written
from a dilTereiit standpoint. I hop.' it will alM. prove u-et'ul
and inllil a want. The -uhjeet nnitter has heen mostly jiiveii
in the form ot lectures to studt nts. and the personal form of
address ha- heen retained, as it seems to present advantajjcn
from the teaching? point of view ,

With the approval of my colleague. Dr. Hector .Macken/ie.
the plan of placing a mark -X" when the |»atient was admitted
into St. 'rhoma>s H(»spital undc his care has heen adopted in
order to economise space and prevent repetition. It is hardly
possihie to speak too highly of the help which he has atTorded
during tin- years that we have heen colleagues, hut the reader
of the following |)ages will he ahle to appreciate some of the
delit whicl; I owe him. and will understand that 1 am not
ungrateful.

I have much pleasure in aeknowle<lgin:; the ^n-at assi>tance
which Dr. John Harold has given me m passing the Ixuik
through the press. Mr. Stewart R( U(iuette has heen very
lu'lpful in tlu' preparation of some of the subjeet-nuitter and
statistics, whilst I am indented to him (and to Mr. W. K.
Bigger) for some photograj)hs.

.Most of the illustrations have heen made for this edition by
Mr. Sewell, whose excellent work is in such reipicst by medical

authors.

William Hknry B.\ttlk.

ll.^l'.I.KY StKKET,

London. W.

September. 1914.

(ONTKNJ'S

I'UI.IAri; .
INTHoDUcnnX,

Tilt. I'l.AN.VINi; <iF AbIxiMIN'AI. In< l^^|(l^•.•*

M ii(il>l |n\.s |!K(i..Uhl\(i AN-r.-'IIIK.-IA

V

I

II

1^

\'\,<: I.

Is.riHIK-' ul im; AlllMiMiA'.

A. Wiiitcii r i;vi!.i.\( K Ul lit film; oi- Ahim.minu,

<'<'\ I i;n I » .
I!. Tiioi^K i\ nifii ir iiri;i;i: i« I.vii.k.m k mi Imkuvai.

Iv.M in ........

"^ri'KHIK |\| 1'kSKTI! Vll\<i (ilN..|r..| ....

l!i I'll in; 1.1 iiiK Aiti.uMiNAt, <omk\is wiriruir Kxtkiinai.

WnlMi :
TllK .•<TuMA( l[.

I'ln; Smai.i, In iksiivk .
Tin; FiAi!(;K IvrK-invK .

ilfK I'AV< KKAS

TlIK LiVKU ....

TlfK (iAM,-Iir.AI>l)Kl; ANI> HlI.KI)l ( TS

I'lrK .■^PI.KF.V ....

TlfK KinvKY ....

TjtE UrIVART Hr.ADDEH .

Thk Apter-Effects of Addomivai, In-

l:i

i:t

I.-.

.

:u
:j8

.-)()

r>2

.

.-.4

«» ^

r,H

.

. (ii

•

Til

jrRiK.«

74

Vlll

CONTENTS

I'AKT II.

I'KltlTnNllIS Willi SpKcrAI- KKFF.ItKVCE To IHK VAEtlKlIO
IlKPKVDKS I (IV THE KVTKAM K OF (JkRMS nv TITK Hl.uoK

Stiikam :

PSKIMOCUCCXI.. StrkPTOcoccAL. Ti HKIiCl I.OIS
Tin: IS'FH F,\<K OF TITF. Ai-CKVIHX VkI!M1F(IKMIS ami FIS i)F-;FASF.-i

TitK |)Fv;v<i.-<is OF THE At ttf: ('oviifhoss ifAVivi; TirF.iK Uhkjiv
i\ TrrF. AiM'KViiix Vkhmifokmis .....

'I'lrK 'I'kkatmknt of .\( ftk .Vpfknukfus wrTir Pkhitovm i-<

Al'l-EVIHt I r.AK .\li.s.F.<.-< •■-...

Otitku Vauiet";.-* of LorAi.isEU Sri-i'i katiov wfufiv iiri;
Pekiton'eum:

IIefATIC AliSlE.^iS ......

Pehkiasthk' and .>>rn-iiiAi>ni;A(;.MATic .Vuscess
Peuiskimoiiutks in < hii.dkex
«'<i\('ealei) AnscE.^sEs ...

PAiji;

S6
!tO

110

11<J
1:51 >

I.JO
141
147
147

PART III.

PATiroLOcicAi, Peufokations of tiff I»1(;e.<tive Tuact:

PeUFOK.UIONS of .><IM1>I.E ri.CER OF TKE .'^ToMACir. Dfo
OEM.M and jKJFSrM ......

Pekfouations iirKi\(i tite Cofhse of 'J'vpiroiD Fevei:
Perforations of 'rrnKR( ri,or.< I'lcers .
Perforations of Divertuii.a of the Large Uowei.
Perforation's of Stercorai, I'lcers

lo2
179
186

188
189

PART IV.

ACITE ('<lNl>FlToNS HAVING THEIR ORIGIN IN THE FeM VI.E
(iENERATIVE ORGANS :

Salpingitis, Pyo-salpinx, Kxtra-uterine Gestation . 196

M'm

cox TEN 'IS

IX

' ^ '' ' I \ . continued.

I'AliT V.

SOMK or ,„K vu.no K.V,:. ,;,v,s,:s .„ nr.-: A. r,,: A„,„.mkv
Ami: H.i;MuiiuirA.M( I'lNCitKAinis
AcriK l)ii.ATATi,>N ..I iiri; Sn,MA< if

Kmhomsm avi. T,r,:,.M,.,.,s .„.• Mkskn r.;,;,. Vk.ski.s .

Ar.iK (•.ru,,,:,v.,,i,s AVI, Pkimuha, „,vs .,f ,„k(;vi.-
Bi.Ai>i>i;i: AMI l!ii 1.-1,1 , I,

TouMux „. ni. ..MKMTM AM. ,.„,.:,: Aiu.nMiSAi. Snnc.

■ 214
. L'20
. 224

rum:

II..:M,.K,nrAM: n:,,M .,as,„.- am, |)ru„KVAi. T,., k,..

SoM,: X,:, KosKs w,,,. ,r may , a, si: Svm,.,,.„s ,„ |•..l:^, v . 22s

2211
2;!li

I'AIiT VI.
OBsriacr,.,vs ,„■ tuk I)in,:.,,vi: Tu.ur .„;,.,.«•
SruA\r.|-r.Ari.,s (,i- tiii: Si,,MA<ir

OB-Tin< 11,.N- OF IHK SMALL IniKSIINK A, 1 ,
iNTlSSrsiKl'lION- .

C»BSTiU(Trox8 or tin: ].uu:i, Ivtlstixi:

V0LVl-I.l'S) .

IIIK I»IAI>I1U KiM:

•

•

2:!(i

r 1 • 1 i:

•

2:i9
26(1

Cl.'l. Wilis

AM,

.

,

2 till

TAitT \11.

<^'XGKMlALr).Vi:,M„n.,M„r UIK.V.M. I.L,

.'SO

AI'I'KXniX.
The Opkuatios ,,k (;a-ii;,,si,,m,

A.A.

2SS

LIST OF ILI.rSTUATIONS

Klu

1. Stkanciiation hi- lMh>riNK in FiiUMi s 15am> .

FkoM a |)l^^F..TIn\ Ol TIIK. Ml SI l.KS nV TIIF. Abix.MISAI,

Wail by Phoi hssoi: F. (•. I'aksons . . . -

:t.
4.

8.

1".

11.

12.

Bavdnf.t \Vi«rM> III LivKi: ..••••

POHTION 111 INIKSTINK KX.l^Kl) BY Ml!. .I"1IN (HorT IN
FIUST SI.VF.SSFl I. . A^F. OF OlM.l!ArloN FOl! TKAIM.VTIC

lUi'TrHF. ...••••••

KXTF.N.^IVE LacF.ISMIUN OF LlVKK, II .1.MI >1!1!11 AGE .
TkAIMATIC La( KHATIHN ANK CONTISION l)F THE SPLEEN .

The Laham;

Oi'Emm: in hie Mfsentfky <if the Small Intestine of
Thai MATH ()1!1i;in ....•••

I'lN IMiOTKl 1>1M^ Tllliollill A rEHFul! ATH >N OF THE APPENDIX

AND I Ai sim: Fehitonitis ...•••

DlAliUAM TO 11.1.1 STUAIK HY SlIADlNO THE RELATIVE Plio-
POHTIONS OF THE VAHInt S PeISFoI; ATION S OF THE llol.I.OW
VlSCEKA ...-■■•••

Appendix, half-size, showimi 1,o( alised (iANiiHENE with
Pehfohation, seiondahy to a F kcai. ('on< HETION, fhom

A (IliLD Willi CENEHAI. I'EIMTOMTIS . . . ■

Athophied Left Kidney i on i ainim; iai.i i li. wiih ii pito-

m (ED SyMPIoMS liESEMlil.lNi: IHOSE OF AclTE APPEN-

|'.m:E
li

24

35
-)6
62
63

87

!IH

DU ITIS

. 116

MSI' OK IIJAS'IRA'IION.S

I'm;.

XI

l'\(,i;

1."!. Dl \(il; AMM AIK l;i.l'l!l>KN I Al liiN (p| SkAIS .,1 MwiMIM

l!i;i i.i'.x I'm\ i\ I»isi;\-^i. 1)1 Tin. AuiM.MiN \i. \isi ki!a . II7

14. I\(|s|(pn ic(|; .\|'|'|;m)1i kc I ii\n (liAiri.i.)
!■">. ■■ 'I'lii; I'liwi.Ki; rcxniiiN •

. li'»

lt». SiMlM.K .Vl'l'AKvn •; I .>i;i> I (.1; llli; rc.\ IIM ,,| V .\i.mims 1 |;.v

TION 1(1' Fi.i iiis jifi- iriiiiw ..... I',-,

17. I"[.INI(AL JlHUWAM Willi im; UkiJU'NAI. I'JII.M KNi.V(;i;< 1.1

.\|'1'i;m>in .\hsi kssks ....... |;[|

IS. DiAiiKAM (II iTiK Paths (H I'kihtiinkai. Imk.hun in

liKI.AlTilN Til .\n"KM)lrl US ..... I'M

r.t. SAciiTTAi. Si:( HON 1,1 Tiir. Fkmam: I'ki.vis

. i:t(i

iM). I)ia(;i;am ki Tin; .Xnatomhai. IIkt.atioss or a 1{ii;iit. sided

•"<l B-DIAPIIIIAI.MA 1 1< .\liS, KSS .... I44

2\. l)lA(;l!AM 01 TIIK AnaTdMK AI, HkLATIMNS Df A LkI T-SIDKD

Sib DIAl'llliAl.MATli AliSCKSS ..... 144

22. (LiMcAi, I)iAi;i!A\i ur Tin: In( isidn idi; Kxim.oimni; tiik

Kiciirr SiDK (.1- TiiK Abdomkn ..... 14.">

23. AclTE I'KUrulJATlciN 111' A (iASTKIC I'LlKli

l.VJ

24. SroMAdl PKIilOltATlllNS. I)|Ai;|!AM lO II.M STltATK MdST

Common l'osirio\s oi' I'i;i!i oiiaiimn .... i.-):j
2o. Pkhiokation 01 (lASTiiic I'u i:i!. Inskktion oi- Si Ti hks

WIlKHK TllKliK IS Ml (11 'I'llK KKMN<; or TllK Hask . l.-,(,(

2<i. To Ii.M sTiiATK Tin; Hi;lations iiKT\vi;i;\ .Ik.hm m and
."^TOMACII IN Tin; ()|-KI!ATlo\ or Antkiiioh Castim-
KNTKKOSTOMY ........ | (i(i

27. Pkufohation or 'rvnioin I'u kk ..... iv.j

2.S. 'I'm; 'rKMI'KliATlKK Al IK.l! PKKroltATloN OI' Tvl'llolD I'u EU

AM) SlfCESSI TJ. Ol'EKATlON . . . . . 1 .S:{

Mh

I

mn

LIST OK II.MSTIIATIONS

I'AUI.

^"■- , r, ,,,,.., 1 Ml- ri..i.ii ... Tin, >MAi.i.

XII

|\ri:sil\i. • • ■

:!l KM)-Tn-KN1> .\NA>rn\inM-

lNrKSIINK^-A.M-I.l.AnHN nl fl.AMfS

V,.,i:i: Kn. IHnN ... SMAI.l,

■ni

-.'41

SMAI.l. IMI.-IIN

1. 'I'm

242

244

SI. 1:m.-i...k.m. .\SA-1..M"M- "I

CuMiM >•. -^ SirntLS .•■■•■

Iv,,. lis. .'.tnli. . isi. 0|1<1.M r.l.iN
:.4. SA.!...MA ny >MA.J. InU-^MM. _^^_^

IN A t'.lll.l> ■ • • '

. 1.11 \Ik<imi.i;v iwA.iiM. nil
35. S.M!.nMAn.r.< TiMMiK '" nil. -Mv.in" ^_

Lt M1.N oi- nil. SMvi.i. lMi;-nsr. ■ ■ ■ •

,,. ,;,,,........: HKMuvK,.n.oMn.i:SM..i..sn>iiNK ...UN.. ^^^

LlFK. M .Al.Kl. Ar.iK 0„s.u.ri...N

;!7. i:i-,i.n .KIN "i an Inii i •' _^^_

urrsii>K. TiiK .VuiM.MKN . ■• ■ ■

:js. 1.1,1 r Ilia. (•..i,..sn,MV. Tui: In. .smN ■ ' '^^

Tin: S. I'l't.nnN.- Si irni: • -' '

PO:ilTl.'N "l <MM:NIN.1 in Till-.

27S
CllLON . • • ■ ■

.MKT11..1I .11 lN^l-"T"^ '" '^''^"'- -■»
TllK OPKUATION CuMl'Ll-ll-.l' . 27'.»

. 2S(>

4.1.

41.
42.

4:5. Lati:i:ai. .Xnask.m.isis

44.

4.J.

4(i. lLr,.i-C'.il..>^T.>MY

47.

4.. Tni: KxTKKVM <M.knin..Txv„Ykaksai:ki:..a-.k,.muMV

2S1

2S2
2s:!
2s4

2>'.i

.jinJc^m^-"-^miR3i::y

THE ACUTE xVBDOMEN

INTHODl'CTIOX
Tin: PJ.ANNINC OV ABDOMINAL INCISIONS

0\viN(i to tlu' t'i('(|UoiU'y witli wliicli incisional lu'iiiia follows
tlu' niaUiiii!; of an alxloniiiial wound, it would he well that
any one cnga<;('d. or li()j)iii<^ to he i'n<,;agi'd. in tlio ))racti(\ of
abdominal surgery should have clearly in mind the anatomical
structure of the parts through which ho will have to ])ass
in order to treat lesions of the viscera whether acute •)r not.
It must 1)0 fully recognised, however, that in some acuto
abdominal conditions it is not ahvays possible, or perhaps wise,
to elaborate an incision ; tl-e (piickest and most direct route
must be followed at any cost. Professor F. (J. Parsons has
kindly made a dissection Avhicli ho has permitted mo to
show in this illustration. It gives clearly the relationship
of the parts. The rectus muscle a])pears. however, as usual in
tho dead subject, more narrow than it is in the living. It then
covers two thirds instead of half of the distance between tho
anterior superior spine and the umbilicus, as shown. This is
im])ortant. as will be seen later on.

There are certain lines and arrangements of muscular fd)res
which must be remembered, and of the former tho most
important is the linea alba, tho second in importance the
linea semilunaris.

It was once tho rule to do all abdominal operations through
one of these lines, and most commonly the linea alba was
selected. For this there were many reasons : — -

1. Such an incision gave direct access to the diseased parts,
could be easily extended upwards or downwards, and permitted

A.A. B

sv^^

: 'X'i^'^'m^}^^ -:

?-.1--'*^-\*3?Sf;t!a^-21.

'iiii: .\( iri-; AiiDo.MKX

llic (i|K'!Mt<>r to MMiiii' tlif iicdiilc (it an n* iriaii liiiii'Hir with
(■(liial facility nii citlicr side. ()|icrati(iii was mostly iv(jiiiic<l
for disease in the lower aitdoitieii or pelvis, and not for acute
coiulitions. oi' fir diseases of the stoniaeh. t^all-hladder, or
a])j)eMdix.

2. The wall was at its thinnest in this lin<> ; therefore it
took little time to !.'et thronu'li it. and a comparatively short
time to clo.se it when tin sur.L'eon had linished.

:!. 'I'here Avas hardly any luemorrhajie to emharrass the
operator, anil in the days \\ hen Spencer Well's artery forceps
wen- uid<nown this was of <:reat importance.

Once it app"areil to he tlie aim of an operator to e.\ti'act an
ovarian tumour from ihc ahdomen through an incision as
minute as possihii-. Jn a short correspoMdenc<> i;i the Lnnrtt
on this ([Uestion I vi'iitured to protest aj^ainst the jirinciple
of such an incision. 'I'he innncdiate danj/er of suppuration
was consideral)!'-. and fear of peritonitis threat, in those days.
K.xperience had iu)t shown the danjrer of suhseijuent yieldiii<;
of tho sear. The dislike of makinj,' a lar>.;e openinj,' oidy
departed Avhen our methods of wound tr<'atment rendered
iiny cut i the ahdominal wall mack- l»y a suri.'eon practicalK'
sa'e. The injury intlict<'d on tlu> edges of a small wound by
the surtjeon's hands and retractors increased the danger of the
sup))uration which it was intended to minimise, whilst it
limited the area wliich it was possilile to adecpiately explore.

We have for a long time reached a stage wlu^i we not oidy
])lan a ])ar1icular operation I)ut try to do it iu such a manner
that tlie abdominal wall at the site selected for the necessary
incision shall afterwards be as strong as it was before the
operation was commenced. We want, in other words, an
incision which uill dve ade(|Uate access to the dis< <o but leave
l)ehind no weakness which can give uneasiness lu the future.
An accurate knowledge' of tho anatomical structure of the
abdominal wall is therefore of tho utmost iin])ortanee. You
must appreciate the ])ecidiar arrangement of the rectus muscle
as regards its sheath, also the e.xtent of the wall wiiich this
muscio covers. The part wiiich the lateral muscles ])lay in
rendering the abdomen secure must also be remend)ered. for
neglect to do so may lead to trouble, in consequence of a badly-
planned incision.

TFIK IM.AXMXc; OK AlJDoMIXAL IXcrsioxs :'.

For imHti,.i:l pui|....s,.s thrtv aiv two imisrular -n.np. the
anterior u...l tl... laK-ral : of tUv fornxT, uv a.....l ...riv nu-nti.,,,
the; r.-.l.-ab(lu!nims. nimiii.g ir„m al.uvc .l.nvuwanl's ; iu H,,.

i

■ ' ■irT:',','"'" ^' ^''^r''."" "* ""• ^^"^' '"^ "'■^''^' -\'"l'"ni,K,l WhH 1,v ]"rofP,s„r
•'.Sne. _. l^.,.tus ,,,u..l,.. r, 1.,.,,, ,,,i,,„stn,. a,„.,v. .; V.,'"
:a.scid. y. Internal oMiqiie. H'. (•<i>tiil caifilii-cs.

B :.'

THK ACITE ABDOMEN

Jatc-Mll^ touanls ti:. ,|,,.,. spiiu-s ov.t u space gn-afer than
s usually alloH..d,onH.nK for ,,u.yr.a<^
oM o antenor sup,T.ur .pi,„. of tlu- ilium ,.u ..a.h si.lo i,. fC

.imiu mmal «all. Ka.h iuumI,. ,s unusual, inas.nu.li a^ if is
;.- ly ....ntanu.! i" a slu.,,.. is ,.,, .,.,.„.,. ..a^.H '„

m' stn.nK 11m- slu.a.l,. al.l...u,r|, ..f «,vat s.r.n.fl.

<..-Iy a„a..|,e.l to tlu- n.usdo wl.i,.,. it n.dosos. .x^i, !
at t u. l„u,,. ..-ansuTsa.. an.l p,.nnits of „o outran] .Lvi i n
'■; tlu. hnoo pull.so Ion, as .1... two are at.a..!.o.l to '., h" y
- nrnjun-cl hnea alba. The t<.n.linous intorse<.tions n^ t t

. ..^'r..,l tl>at suppuration Mi,|,i„ ,1„ aJulon.en .vhieh rem,iros
» "-"M'l.'y.nent of drainag.- aft.,- inHsion through h b
< omnn.l wains hlu-ly to b.f..,, ..1 by w.-aknos' la " o ':

I. >aroapt,o,h,l..PMnh,.irn.plK.wlK.naskc.,ltlK.ir.^xp.rien e
-"-nnng nu-.s.ons whi,.h have- not l>..n ..onn.li'rtod bv
suppuration eitlur befon- or after oner.tin,. ';'''"'' ^-^
nrliiilt ti, .( 1 • "IH'i.ition. Some do not

a.lM m that herrna occurs in their practice, others perhaps
confess that operation is followed by weak.iess of tl^ ^^^n
-" a snndl penvntage of dean ea^-s. It is of eo r e " !
-"'•yn.^' to find that a patient for whom an expl ra ,r -

•US ' '■■ '""^ •''■^•"'"P"<l a ventral hernia which is
causnig n.or.. nu-onvenience than the trouble for which he
uicision Mas made. Whe,. f)w> ,..:..;....> . '" '"^

•something wliich re(|uired a h
or the patient knows that life

Tigmal operation was for

'iig and difficult manijHdation.

isposition to gird at the operat

tor

(leveloj). and less surp
t is met with. !t must be recognised.' 1

as saved by it. there is 1
•hould a liernia afterAvards

ess

iise is expressed by tli

c surgeon when

tl

present day. with our greatlv improved

owever. that even at

impossil,le to g-.arantee ab.solutely tl

teclui

que. it is

alba, whether made abov^ „. „^-,^„ ,
yidd during after-life. Convalescence

liat an incision in the linea
or below the umbilicus, will not

may have been quitt

THE 1»L.\\XIX(; OK AHDOMFNAL IX(I8I(»\S .-.

IHTffCt. II., ...,U:;|, t,,,.ll,l,..l llu- l.atl.Mt, Mn, ,|i,| tlM- u.l;...-

«l"-»'" ..u>o uM.lu.' stn.il. or v..i..itii.y, vH tli.- ...,,,|,.,,sa..f fact
rcn.a.i.s aiul l.as t., 1..- lacc.l, a l.ni.iu ii.av (..,.„ i„ spit., uf all
<•"!• car.-. All scar fiss..,. has a fc.i.lnM.v t,, ,n.,ira,t. I,..t this
may l.c mvnomr. aii.l th...',. an- s, ....Jal ivasniis whv a cicatrix
.S...UI.1 stretch uh,,, it ,.Mt..,s into the tnrn.ali.m ,.f the
Hl>'lo....na: wall. lu every i.art ..f this it is s..i,j,.,.l,.,l to th.-
actio,, of two forces.--{„) intra alMloinii.al ten im, which
varies consi.terahly at diflerent tint's of th,. -lav a...i tends
to a more pern.ai.ent increase as ue ^et uhh-r and nmre
snlentary .n our hahits , an.l (/,) th.- action of th.- n.nsdes
of fi.e «l„h.n.en. which again is of varying' power, and sonn.tiin.s
indeed violent an.l invgular. in .■ons,.,pu-nce of diM-as.. Th..
n.tra.al..lo.ninal p.vssure is fVlrly ev.-nlv .listril,..t..,l ovr tn,-
vh..le of the ant.-ri..r part of the al,.h.i....n. I,„t in a.hlition
over the lower part .-specially, th.-re is th.- a.l.le.l w.-ight .,f
the ahdonunal c.ntents when th,- patient is either sittin- or
in the erect position. "

It may h. aske.l what kin.l of inei.sinii shonl.j he siil,stitiit.-.l
or those through the iiin-a aiha an.l the lin.-a. semilunaris.
It IS ol.vious that if the re.-tus mus.l,- can he t.-mp.,rarilv
'lisi.iace.l to ..ne si.le .luring an op,-ration. an.l i.ut hack
umnjured in its normal ),e.l after the operation J.as l,.-,.,.
ini.she.!. there will Ik- no ,.o.ssil,ility of th.- d.-v.-lopment .,f a
iH-rnia at the site ..f the incision. In th.- operation for th-
n-moval of the aj.pen.li.v whi.h I sugg,-st,-.l manv voars ag.,
and have practice,! r,-gularly si,u-(-. a.lvantagi- is "taken ..f the"
anatomical arrangement of the rectus. An op<-ning is made to
t ho inner side of the linea semihuiaris through the anterior
sheath of the muscle, the muscl,- itself is .Irawn inwar.ls with
■■I retractor, the posterior sheath inci.se.l. the app(-ii.l,.x ,em..v,-<l
and the incision suturo.l. This ..peration pos.s.-sses manv
advantages, not the least important ..f which is the .mssihilitV
ot oxtemlmg it to any reasonal.h- tlistance. .Mo,li(i<.ations o"f
this metho.l have since been a.h.j.te.l f..r ot h.-r op,.rations
the advantages of if being .so ol)vious.

At a^i appendix ..i)eration. if the right ovarv or tube he
toun.l .l,sease.l and re.|uir.-s rem.,val. this can lu- done Ihn.u-h
tiK' same mcish.n. .Shoul.l the l<-ft ovarv ..r tube „-,,.,ir..
removal, it can be excised tliroutih a similar in.-isi„n ..n fh.-

''■"^- \<rTK AMDo.MEV

•tl lj,r

"""■ "'""^ ' " I'-'l... .nil ,,„

"'fur si(||.

I.r (•■(I.

:' ••-' '•" n^: '■;;!: :::':; :f •■•■'•'<-... ..,,..

:^'•''■'••'''''•''•■'r/.^,. J:;: ';;;;- .nti..,, .,....„,

'•• ''-•<-nr;.^:;';:r «'—•.-

''"•••--'•'''•'•'l-.r .;''''''"■«"' '•'-'•'--'<! M^

"""""••"• "'"" '■» i' i^ M Ml, ;;..'"" ""■ '"""<•<''•'"<■ a»„.,..

If •! 'II.MIC tlll'dllirji I 1,. l;,,, .,

, " "'«• ai.l.Ti,,,- sl„ ,,l. „t ,.,, ,, '""" ^'-""l.i.Mris.

"^' "- '''•"l-.niMal J, ,'""''*• ^* •""•""-.,....,., M,.ak,u.s.s
''"'•''A'^i-- l-'t >la- n.,.,„s ,.,',1 r'!!!!'"""" '"'^'"'^••" ^'t a

'•^ '••MU-.li,.,|, ' l>f.l,.c(|y ,^,,„„ ^,,,^,,^ j,,^_ ^iJ^^.^^.^

;'•'-: »'-■ .lander is s,i I, ';V'*'*'^''V''"''''''''^''' '•'-•-
im.,l,u.il>l, v,.M,,.all,..mi!'' ' "'■"■"' '^""^'"W for a,.

""•' ."•"^^•"•■'!- fu..„u.„tlv t.;, i ' '"; ' ;"■'■ J*""*-'' "Pwards

ti'e weak u.i.ion wil, i^'l . , ^l^ i;'"-"' '-'^ -'"ii-uris

'^t^"td. .IS those Inu.s are really

•1

THK l'L.\NMX(; OK AHDoMIX \L l.\( ISIONS

i

1

iiiHcrtioii^ ul I lie liit(>r,(| miumIcs, h i> not lUMtssaiy |ur fho
wrak H]uit tultcii liiin<'..iiciii tlu-liist iiistjiiirc tm- 1 he utiicittiiiii
M'cms tn hiivr III.- |,<.\N,.r .>t liiiiliiiK d,,. ,,,usl ruiiiiitc ami of
(liliitinu it. \\V ,,\v,. iMiii'li III tl;»' uinrntiiin fur tin- ii>c nf its
(lff<-M>ivr jtuwcis ii;.'iiirist iiitiii alMloiiiiii.il (lisi-a^c. and ih'|Iiii|H
its imsliiii;,' (liaracicr and iiisiiiuatiMy _ ..liti«'s in cases of u
<lcf.Mli\f alidnihiiial wall arc only i'liclVoit of Nalmc toj.'ivc llic
mdiviiliial caiiy iiotic*' of his ilaii;^! 1-, so iluit lie iiiav rriiu-dv
till- fictcrf ill his aiiiiotir as soon as iMissjhKv I'.c tlmt as it
may, such wariiiiiirs should not he so fiv(mciitly iic^^'lcch-d.

Not only. then, arc incisions in the iiicliaii line vfty lialdc
to he followed l)y hernial protrusion possihly years later, hut
also those which have l.eeii placed in th(> lin.-a seiniluiiaris,
and for a similar reason the lateral pull of the muscles, which
is so ditlicult to rejiiilale and control, .'n Doth these situations
there are practically only threi- layers which prevent a j.ro-
trusion from formiiit;. and an incision through the middle
hiyer places a weak lin<- l)«'t\vcen periton<-um and skin, for in
the prevention of ahdominal hernia the resistance of tlie
skill, and iinleed of the peritoneum, may he lej^arded as iioii-
e.vistent : tlu-y an^ hotli of them too elastic ami easily strotchetl,
even when uninjured, to alT rd any permanent protet t ion!
1'he aponeurotic structures constitute our main reliance, their
value after divisi(»n a;;ain de[>eiidiii<^ almost entirely on tlie
accuracy of apposition secured l)y the method of'suturing
ad<.|)te(l. If the line of suture is not accurate hut irregular,
the edges not meeting w*'ll, then we must <-.\pect to have a
weak sciir— iiuleed the wonder is, not that we occasionally get
one. hut that we do not get one more often. 'I ne edges'to
he joined are eoininonly so narrow that tlu-y can rarelv he in
l)ert>et apposition over the whole length of fiie incision." IJuth
this hiyer and flic^ peritoneum must Ix; sutured with the greatest
care, for although we may hold it as a fact t hat if t he ajioneurot ie
layer l)eeoines ])erfectly united no hernia will ilcvelop. sliould
tiiere be any depression in the jieritoneai line of suiiire you
may be sure that a piece of omentum will find and iu-imiate
itself into it. By this means, and also as a possible result
of tlie inehision of a ])iece of omentum during tJie process of
the insertion of sutures, a great pressure may be exerted on
the aponeurotic union at one or more points, o. ch may

THE ACUTK AhDOMKS

^ '''';nH ::^^,^ .„.,.

•"••"••'(.V .hoMM. ».„• /...«.., i.ii.,. "■""'"""'• ""••■ ""• li..:

"": ^••»M,sv..rHalis fasHa L '''•^'•.'" '" ' ' "«-»"l. I...t

"'""" »'" "-'-.St in Uvi.L '"'■'*■ '""' *'^ '"■'••"•at..

"""•'""'-'"-'• i^iH^ ;;;/:•;;;;••;!-•'• «'-'''.i....K.a-:

"""•'•'""■^« Kvr. a„.| as a ,,. "" ''^"'••""•"iii as tl.u

''''''''''-•'-'■-lit! ;;':;:vr^'' •''•■'' '^^

;-J«<ry as n.nel. as j.ossilW '"'r "".'■ '" '"--v- i. fro,.,

-• "" tin... ,.-|.ic.|. is ..htain^d^^s ;r "'""" "'"^ --'"v
''=;'; ^^-""Hl k.j.t f,,^ fron ,'"'"'"'*"•""■« '"''^"l anil

r"""-- ^ «'•' -'t nn-s n?.., :";'•' ^"■■"'' - -'--e
'"•"«''y Xo. i) for tiu.'sutu, " "-V T ""'^"'■''" ""'" •'^i"^-

-turo,ivosnu.aK.ns.ot^,!^ ,;\J';^ *'^ ---n.I.ted sill.

i>'-nalex,K.nenc.e.i.aveC X:;';;';? "'^ 7'"- "^ "-y

»'anii,.i\., vmpl.nvd catgut,

!

I

TICK I'LAXMNG OF AHDUMINAL [Nrl,s|o\s ..

""' ^'";. "» I'- ^"..M«.|, ,h;u. .1,.,, ... N., I. ivrhap, I H.n
|.r..j„, ,...., . U, I ,.,„ „.,t ul.m,. M. M.s ,.,......,■........ fur .ilk. tor

Mr Altn..l I',.,,,.. (;.,ul.l. uIh.m- <.N,M.,i,.,„... j, 1,,,^,,. „,„,
a.Un.;,t.., .„ „,.. ,„, ,„.. .1,.,,, „„,„•,.,. A. -.„„.. of vnu ,nav
kn.m. I |,av,. a.lv.....| ,lk !..,• tl... runt.,..- M.liitr. n. ll,". >.• .a.,.;

»"••■ immy y.-ars i„ ,|„. Ir.-.urv ton,,,. a„.l „>..,| ,, i,. ,|„. o,,,-,...-
irm th.atn.. Ko,!,,.,- a.sk,- : • Mou- ,a„ p.-o,.!,. .o o„ „.,„„
'•a..,M,l to,. M,t,„„,. tl.r wall of ,!„. al„|o„„.„. ,,Uvn M,,U-\u,Z
M^ n.,.on|..,| ov..,- a h,„Hln..| .aM-s ul.nv .he «o,„ul l,as
liii,sf o|K'ii lifcaiisc <.f if ; '

If tl... s.„p.o„ has ,o o,,,.,af ..ui.klv iHvans,. of ,!„. „,i;,.,„.v
"f tl,.- .a.,.. fh,.„ I,,. „,„., ,„,,,,, ,,,,,„^, ^,,,„,.^,^ ^^,^^^,^ ^^/|l

'"•■'"•I" '• I llM-lay..,so„ Loth si.l.. of ,h. uo„>,.l. a.nl tUvu-
ar.. „o,„. |„.,t,r fo,- this |M.,poM. ,ha„ th.- larj^.-rsiz.-.l li>hmit
»l",.h IS n.a.lily s|,.,ilis..,l, ,„ak..s a p.o.l k„ot. a.,.1 n,ll ivsist

<"'y ^fail, ThlH ,UM.l..s.si|y for ,Mpi,| .,,,ti.,;; is |o„,„l i„

'■as<-s ot tlu- -a.M.t.- al.<lo„„.„- i,, sfo,„ a.lulfs. uhn, Iho
"I"-'- .lo,. ,n„st Ik. ,api,| to Ik- s,„c, .ssful ; fh-,v is a.ioth..,'
point in fho ,i,jr,.,„ op,.,,iti.,Ms for this .luss of .as,. a,..l f|.a(
IS the i,.,.,sio„ thro.iuh ,h,. s,.„,ii„„aris shouM |„. chos,-,,
tiH,l,onif,.|y, as this yivcs imuU tho K-ast .liflin.Itv uh,.,, it
;_;;n„.s to (•los,.,g thc> wo„n.l an<l tl.,- sur^'co,, is short .|,an,l,.,l.
IK' p..ss,|„|,fy of u h,-fniu aftc,' rcov.Tv is ,ioi x^orth a
•"<',„e,.ts na.si.l.Tatio,, i„ .s„..h ....sc-s ; if ',a„ |„. ..asilv >.ut
r.gl.t l.y u s,.co,.,l ojH ,atio„. I,, th.- ,jnli„arv ..FHK.tio,, wh, .
tho su,g,.o„ ,s ,iot hiirriod. tho alKlominul wall sho,,!,! !„> ,.|os..,l
'" layers : f.,,-ly.four out of th.- fifty.five ikruum ar„l Austrian
s.n^j:c-uns ,,„otc.,| |,y |)r. SwaHi.-l.l wm- in favour of fhi, pn,-
«•'•<''"■<■• -",,1 It agn-cs with th,- ..xjH-rionce of ,„ost H,itisl,
^"r..,.ous. fh.. „„po,.tanc,. of oju-ratinjr .-arlv uh,-, a wou,„l
shows s,.Ms of yi,.!,li„fr Ja,,.r on. iM-caus,- of the- j:,vat,.r lu-ucfit

" '><• <li'nv,-<l from the o,„.,atio,, wi,(-ii jua.-tis, „ a s„,all

'''•'""I- ".u.st 1„. s,.If-,-vi,l,.,.f : th..,v is also th.- su.allor risk
"^'"i<'l«;'ati,mof.l„)rt ,lu,-ati.,n i,v r. ha.l tvp,- ,.f pati,-,it to
'-'• considmnl. for shook is al.sont. an.l tlu- a.l,„i„ist,ation of
■"> ana-sthol„-^„cocl not be prolo„g«|. or ono „,av l.o o.nplovod
'ooally In harl .-asc-s wo oan u.s,- fho i„tra-v,"„o„s iufus'i,.,,
of a sohit,oii of h,-,lo„al.

It n.ust „ot be- forgotton that „,us-I,-s that hav,- )„■,■„ co,,-
"aotnl un(U.,.go ohungo, so that aff.-r a !o„g Interval of (i,„c

10

THE ACTTE ABDOMEN

it may ho iiiipossiblc to stii'icli tliciii to their foniicf Iciigtli
suiricioiitly to cover tiie weal; iilr.ce in tiie alMloiniiiiil wall.
[ tliiiik tliis statement paitieulaily applies to llie lateral
muscles on the spinal side of a hernia t'ollowini; an incision
through t' upper right rectus in an operation for treatment
of some hepatic disease.

The hernia' which occupy tl e middle Mne hclow the und)ilicus
sometimes assume rather staitling propoitinns. falling down
between the thiglisand causing distress hotli from 1 1 ('dragging
of tlieir contents and their occasional disturhance or inllamma-
tioii. Their formation is therefore a. real dangci' to he guarde(l
against.

luthehcrniiv which follow incisions foi' tiie relief of appi'iidix
abscesses, although nuich may be done to ])i('vent tiiem by
the gridiron method. tl:e skin and ]ieritoncum lu'c^ine joined
togetlu'r in a thin cicatricial layer to which the omentum is
often adherent. This covering may be dangerously thin, tor
sometimes it does m)t much exceed the thickness of |)aper.
Hernia is rare after operations on tlie kidney by the
lumbar route, if the incision is made oblicpiely from above
downwards aiul the fascial planes an- sutiu'ed after the

o))eration.

Never cut across muscular fibres unless it is absolutely
necessary from th.e jiarticular lU'cds of the case : muscular
fibres must always l)e se])arated. not cut. and as the aponeiM'osis
of the external obli(pie f(.rms the strongest layer in the lateral
wall, incisions shoid(i follow the direction of that muscle. Tliere
are nerves likewise to be considered, and often a little care in
the arrangenu-nt of a wound will restilt in the avoidance of
any injury to them. In sonu> instance s when the hbres of the
rectus have been sjilit in the ])erformance of eholecystotomy
or gastroenterostomy, without refereiu'i- to the position of the
lU'rves. tiiat i)art of the muscle to the inner side of the incision
has undergone atrophy and a hernia has consecjuently developed.
At Czerny's instance Assmy investigated the after fcsults of
cases in wiiich a ^ide vertical splitting of tlie rectus fibres
had been ])erf..iined. and he showed that an atrophy of that
])art of the nuiscU- dissociated from its nerve supply always
followed.'

' .Moyuihaii, •■ Abiloininal Uliuialioiis," l'. 'Jl.

TTTK T'L.\XXTX(; OF AMDOMIN.M. IX( fSIOXS II

Till-; AiiMiMsTKvnoN oi .\s.i:>tiii;m \ in .\( i ti:

<'()NI)|i IONS ()!•■ THi: Al!I)().Mi;\.

Dr.Z. .Mriuicll. who has iin.st ahly a.liiii!ii>l..iv(l aiKc.-t hctics
tor IMC for some years, advises as follows : ^-

•• For the successful pciforMiaMcc of an operation for acute
Hb:l..mnml .iisease, fh.- uwthod of anaMhcsia an.l choice of one
ti) l)c used iiiu>t he carefully coiisidcrcil.

•■ In Ihe first place the pati.r.ts are ;icncrallv .Miifcrin^ from
more or less severe toxa'mia due to absorption from the
'^'"'•""'"■■'' «on.lition. an.l secondly, it is rarely possihl,. f,,
prepare them for o|)cration on account of uriicney.

■•(;cnerally .peakini:. ether should he selected" an.l <hlor..-
t..rm av.M.le.l. an,l in the less sevn- cas..s th,. or.linarv nitn.us
oxi.le (thcr s,..,uence may l.c Use.l : the numh.r of " ca-vs in
wluch a ,.erf.-ctiy satisfa.tory ana.sth.sia can he ohiainc.l l.v
this means varies .lir.ctly with the skd of the ami'sthctist i"n
the use of this method.

•■ When morphine has been jriv.ri 1.. .fore t lie operation it is
usually p.,ssihle t<. obtain aiKcsthcsia by means of open ether
that IS ether dn.ppcd <m to a Skinn.'rs or Schimmelbu>eh
mask : there aiv. how..vcr. many cases in whi.'h a preliminarv
narcotic (m..rphine. scopolamine) is ina.lmissibl.-.

•• In cas..s wh.^re there is already s..vere sh.uk th.. iv>p.,nM-
bihty ot the ana.sthetist is j.nvat : the .-omliti-m mav app,.ar
to l)e d.-sp,.rate. but usually the ana'sthetJe is taken better than
w.mhl appear t.. I,,, likely. Merc the minimum of the aiues-
thetie must be used whi.di is compatible with the n..c<...arv
surgical manipulations, an.l th.. less aiuesthefic us,.,| tlu- l.^ss
additi.m there is t.) the jm.-e.xistinjr shock. ().xvf.'en must I,.'
us(..l tre..|y to counteract any ..yanosis. and sahii.. infusion
subcutaueously. or if n..c(.s>ary intravenously, should b,.
resorted to at th.. eomuK.iuemcnt of th.. ..p.'rati.m. 'i'he use of
strychnine an.l ..thcr car.iiae stimulants is t.. be .lepr...at..d
Tlu.})ody warmth must !><■ maintained : th.. room sl.oul.l b.. k.pt
at a temperature of 7n F. : the body must n.)t !).• unn..,.<.ssaril\
<'xp.,.,..l. an.l th.. leus an.l arms uiay b,. ban.lauc.l an.l eov.r,.;i
with cotton W.M.I : any saline or loti.)ns us...! niu^^t b.. sliuhtlv
above tlu. ))ody tf.mperaturc.

"Children take ,.(lu.r well, but ar.' spt.cially lial)l.. t.) the

12

THE ACUTK ABT)0^rKN

V

coiiditidn known as iu-idosis ; wIkmi this is |ircs(iit the daniicrs
of a i^ciicral ana'stlictit- arc greatly increased when tiie hreath
of a patient smells of acetoni' or wiieii there is the acetone
reaction in the urine. etliiM', and esjjccialiy cidorofornu are
contra-indicated, and it is in such cases that intras|)inal
ana>stlu'sia is specially useful.

■■ For some years in America, and more recently in this
country, a mixture of nitrous oxide and oxy<ien in di'finite
percenta<ies has been used for prolonged oj)crations. In severe
abdominal conditions it may be used witii advantage, eitiu'r
with or without nerve blocking by means of novocaine sub-
eutaneously. This without doubt diminishes shock, })Ut the
method is ditHcult and has its limitations.

■ At St. Tiiomas's Hospital h 'ional. and els( where ether,
has been used intravenously.

"The most dangerous ju'rhaps of cases met \\'a\\ under the
lieading of the Acute Abdomen are those of acute intestinal
obstruction with conscfjuent severe vomiting. When an
ana'stlu tic is given in such cases, gri'at care must l)e taken of
tile position in which the ))atient is ))laced ; the liead nuist ])e
on a level or little below that of tlie body and turned to one
side with a gag in the mouth, the danger lu'ing that of inhaling
the vomit into the air passages. Here again intraspinal
ana'sthesia is indicated, and more recently we have been using
intratracheal etlier : with this method, as soon as the catheter
lias been passed into the trachea, all dangei' of inhalation of
vomit ceases.""

PART 1

IX.inUKS OF TKE AHDO.MEX

CONTUSIONS

For j)iir]>(>st's of cliviriu'ss it will bo hfst lo divide tlicso
injuries into two gi'oiips : —

A. CoulnxiiDit iriffionf Jttipfiirc of l/ir Ahdominttl Contcnl.^.

B. Conlnsi s- i)i irhirli tlicrr i.< Evideticr of I)ifenitil hijiin/.
A. Tlieso contusions are of varying degrees of gravitv.

• "ording to the severity of tiie injury, tlie region of tlie
donien stiuek. the ])hysical condition of the individual,
his ])rej)aredness for the hlow. the time M/iich lias ela])sed since
the last meal. etc. .\ny contu>ion of the abdomen niav l)e
serious, and it muNt be remembered that a patient without
sym])toms of im])ortance, when schmi Houn after an injury,
may be sulTeriiig from a rui)ture of the intestine or other
internal organ. whicOi will prove fatal if not recognised in
time. Such oases liave 1)een only too frequent in the historv
of sui'gery. and whenever the cause of the injury has been
■■possibly'" stdJicient to jmnhice internal damage, liowc • ;
slight, the case should be taken under observation and carefully
watched. There may be no bruising of the skin and yet
there may be a rupture of the intestine. In th e days, when
football is so ])opular. it is hardly necessary to sav that a
contusion of the abdomen is frequently followed by severe
|)ain. shock and vomiting, yet tlu' etfects pass off in a short
time. There are not many cases recordeil in which the shock
(■'' a contusion without internal injury has proved fatal, but at
least one is kntnni about Avhich there can be no doul)t. On
the other hand, the absence of an lumsual amount of initial
shock has been fre(|ueiitly observed when an injury has been
inllicted which lias caused death in a few hours

The amount of extravasation of blood following a contusion
of this part of the body varies much., according to the nature of

i 1 ■■'

14

tl

THE MVTK ABDOMEN

t .M^,ury, but ...ynn.l sftTM-ss arnl ,..!„ on .novnncMf . Mvdlin.
.he usual .I,sc...lorat,on of ski.,. ,lo.-s nof as a n.l. phkIuco
c'on.ruuMl .noonvernem-o unless tlu-.v is assoHal.-.l w„h i, a

;rrv"r" '"""'•';''■ !""'*'• '"—"-i-tiH. ....... of

place n. the suh,H.r,ton,.al tissn... th.-,. was a lar,.- ar.-a o
.h.noss ovc. ti.o fn,nt of ,1... aL.ionH.n nof att..^.!,..! Mi.l
*^f7'^'"M'''*' •''■'''■' tin- pmton..al..Hvity. If ,l„. bloo.i is
not absorbed, a flui.l sw..|linjr n,ay be lonn.l lon-^ afterw.nls •
>n one ea.s,. [ oi„.ne.l su.-l, a svvellinj,Ml„. <.ontentsof ul,i,.h we.v
serous. Mine, persisted ,iv<. years after an injnrv. Sunpura-
fou may follow but is not eonunon. vet in ti:e ;,...! il n.-.v

<•an.se anxiety, and an early ineisi s indieated should tl,«'r'e

be evidence tliat it lias eoinnieiieed.

Hui.ture ot part of an ab.lon.inal nius.l,. is not miusiial as a
H'snl ot a direet injury, espeeially if tin- ..on.lition of the
...US., e has def ..riorate.l from some illness. The patient will
•■ou.pla.n of loeal pain oii niovenu-nf. and ten.h.ness of the
l>-. whilst a.lefeet may be felt one.xamination wlu-n themu.sele

..sput intoaet.on. >Sueh au injury, if involviim a , plete

"Pture of the reetus mus,.le. .ill .iv,. rise to n.ueli diseointort
but not to a hernia, in rupture of the museles. on the laterd

aspeel of the abdominal wall, a protrusion mav be f id as !'

ff.nporary .-ondition forming' at the .site of the hurralion or
as a p<.rma.ient one from yielding of tin- s,.ar tissue forme.l m
tile jiroeess of healing.

An operation for tlfe closure of such a weak spot is indi.Mted
J-'a..se. altlumgh the .laiiger of strangulation mav appear
ro.note. a truss is inconvenient, is not always easik \Jui in
position, and does not ,)revent an increase i,, si/e '

Muptuiv of tlH. recti muscl..s is soiiietinu.s seen as a result of

ml.Mi.se stram. during parturition, vomitiim. t,.tai,ic spasms

ami gymnastic feats. J'.'ofessorAI,.xis Thomson savs t ha it has

H-ou chielly observed in cavalry recruits, thn-ugli a, mm

^•"-•-" a horse without placing th<. foot in the st irrup ' °

I lu'se ruptures always occur in the lower part of .he rectus

musce. because of the absence of the posterior laver ,;;'"

sheath ,n , ha, situation. There is violent pain at the site of

- rupture, with inability to straighten the bodv. uhicl. is

k(pt flexed to prevent traction on the part. There is found a

*Sf-,i'.'V;*^fr

INJURIES OF THK ABDOMEX

I.-)

very toml,-,- swdlinc; in ono si.I,. of ,1,.. ,„i.I.IIe lin. : , his suHlin.
i.. c-luely i,n..l»,..d |,y .xtravasaf o,. In-Uvovn fho rupturod
ends wliich are coiioeak'd hv it. '["""'i

In oases where operutionVa.i be ,.orf„rMied the sheath „f the
muscle should be op,.ne,| and theends sutured : i„ this w v '

pat,e.U will obtain a stronger u, and reeov.r nl.t : .d^.fdv

Should h,s eondit.on not p,.rnnt of ti,e operation, lu- si ouid }h'

pmjedonnsbaelinl..d.insuehapositiontlnu

A all sfuilj rela.ved. On a...ount of thestr.M.crth <.f the anterior

slK-a !. o the nn.p..Ht i:nnnKH.ssary to n.d<;the pati^^.^^^^
.1 tiuss afterwards.

The rupmres of the ,liaphra,Mn whi,.), o,.nn' ind-.pend.ntlv
o^^ gunshot woun.ls. stabs, ote.. are usnally f...n,d on , le
loft sule and are prod„,.<.| by a sud.len and great in<-re e
of ndra.abdonnnal pressun.. Severe nu.seular Efforts J ,

..,.n,ng ,uHl pamu-it^ion. havo eaused this lesion, but the"
• , ,'' '":^ ^'";:''.""* •""^^'- ^'^ i'^ "'<• !>Htic-nt who.s. ease is
recorded m the />'////./, Mcfiml Journal of Is.ls.

iI.M-c. a „,aa of 2n uas a.ln.iti..,! (., S,. yu>vx\ H,,.,.!. ,1 - mr ■
from piKMimot horav an.l .liii)Iu-i,.n, ,t i,. I, '■"•W"""'"'-'' Mincnii-

s;i;:t::!,:',:;-;;,r' -• — ";-:-'.."':::;m'1;:;;^

B. When c,nnph.ate.l wit), injury to the viscera, tliere h.s
hv^ son,e s<.v,.re vioic-nce inllicte.l. such as a crush h JZ
buffers ni shuntn.g. or tin- subject has bn-n run owr.

who ha.l falluu frca a sea.loM is mv." li, ,.".';"'"' ''-'"' "^

A wcnnul of the diaphragm may be very readilv produced
- stab fnun a kn.te n, . ,vil brawls or a lunge fron'. a bavonct
m warfare may produc-e it. e.ther fr-.n the front or th<. si •
I .s then hkely to u- seriously con.plicated with u.jurv to !! :
of the viscera and dangerous ha-morrhage. If th<>" patient
recovers fron. the in.mcdiate dangers ineidomal to such wu n

f^'^'^mr^

16

THE ACUTE ABDOMEN

ho uill very probably dovi-loj) a licniia into llir pleural cavity
at a latter date.

A good (>.\anij)Io of tlic course of such cases will ))o found oti
p. 2:w.

A rase in which a r-.ii)ture of the diaphra'.'m w as associated
witli escape of viscera into the chest wn- operatcil 0,1 l)y
Mr. Jicrry in the Royal Free Hospital.

Male. iiK<Ml 1;). ImtlVr Hccidi'iil . Adiniftcd N'ovoiulicr 11. ISIIS. in ji
st.itc III collniisf, r. ith sui»er(icial cvmIciu'i' of iiijiiry over the iippiT part,
of Ilic af)(lofiH'ii. ill tlic loin, ami over the Icwir rilw. \o air coiilil ho
hoard in tlio cliost holow the third rih on the left side, and the loff .side
was dull hohind tlio niid-a\illarv liiio. Wry mariifd jtailor was a
prominent siirn. 'riieie wa.s niiieh sickness (hei,'innin:r ,„, the
third day), the vomit hein;; colVee-eoloiired. ^'reat thirst, and not inneli
]>ain. On Xovemher 1,") the heart was evi(h;ntly displaeed to the ri;:ht
and a tympanic resonance extended over the front of the left ehesi
almost to the clavicle, and hlended Ix^low with the ahdominal resonance.
A "hniil iVti'ndin" was heard over the tympanitic area. 'I'he lireath
soinids were normal over the riu'ht Iniiir. 'I'he diaj^niosis lay helween
pneiimothorav and j;aslric Iieinia. Operation, midnight <ir Kith. A
larjre hole was felt m the diaiihrauiii. tliroiiyh which alioiit half the
stomach, the tran.sverse cohni. the diio(hiiiim. Inilf tlie >plceii. and the
upjier lialf of the l<-ft kidney had jiassed into the thorax. The hole was
as larj;e as a inin's list, situated hetween the diaiilinium and the last
ril). 'J'wo stil cs secured the liver over tli<' oiieiiinu' after rxluclion
of tlie protrusion. The patient died at the close of the opeiali<ni.

It is ])ossible in performing an operation for eni]>yema in a
cliild to ])ass througl; the (lia})hragin when making the incision,
if the lower part of tli«> pleural cavity is obliterated by
adhesions. Such an opening siioidd b(> carefiilly sutured anil
the ])leura drained at a higher point.

In gunsiiot injuries the diajdiragin is fceijuently traversed
by a ball, but the injtny to this muscle need tiol be s])ecially
considered, as it is ])rol)ably unimi)ortaiit compared with that
ifillicted on the other structures.

J'Vom the great dang(>r of dia])liragmatic hernia which almost
invariably follows rui)ture or wound of the (lia))iH'agin. such
injuries slioidd be repaired as much as jxissible by means of
direct interru])ted sutures when the condition of the patient
])ermils. The transjjieural route will be the better one to use.
1 cannot to- strongly ini))ress uj)on those responsible for
any patient sulfering from an a1)dumijud injury the iinportaiu'c
of watchuig tho pulse. Jt is necessary to insist tipon a careful

I

} '^~:

'- i\. . I- %, • -At «"<•».-nz^J■■.fcX^-■■-'■■;. -z.,. Aj:. ■ .

INJURIES OF THE ABDOMEN 17

oxaminati.m fro,,, hour to J.our ; it is „ow „,anv veurs since
I tn«.,l to M„i,n.ss tlu. in,po,-ta„.v of this carHul Jhs^-rvutio,,
up.m ,„y jmMo,.s. a.Ml I still strongly „,•«. i,. Tl,.- s,.,all pulso
ot the patUM.t With shork shoul.l „o, i„,,,,,M. i,i {n.nuJvv i,i
cases ot siMiplo r.mtusio,!. wl„>,. tlio shocU is passin.r uwav ' Jf
"t .I.H.S so. u.,.1 tho tcM„pn-atu,v is falling, you Jia^^. a .lauger
signal wh,,.. ,nay n.oan ,nu.h. Othor signs of i.nporlanco
to wh.ch n^t.-ren,.,- will Jk^ ,„a,l. later, a.v severe local pain
ngidity (.f the al„lo,ninal wall, ahe.-ation in the pen^u'sio,;
note, eontmued v..,niting, and an an.xious and distressed
appearance. A rise ni temperature niay indicate the need for
i-xp onition. but less in,portan<-e ,nav he attached to the onset

0 distension unless other synipto,ns show it to be the result
ot an mllanunation of the peritoneum.

•Mctc.ism without any le.sion that can be found ,m ab.h.minal
<"xph..at,on may .•e.sult from a simple contusion of the alxh.men.
.S.me y.-ars a-., a Imy of 12 was a.lmi.t.Ml ,„ .st. Th„.uass llosnitU
u.ul,.r ,ay ..arc. aa.l a so.n.wha, rapul .lis„.nsi,.u .„ ,],.. h.i;,. 7^; u
n.sc „t fcuperature ws.umI. TI.t,. was. how-vr. n„ ri^i-litv s ," ' ■

..up lamr o, pam. or vo.ai.ing. Tla- .vsuh.ut assistaat.su,;....,;V.xp iorcd
tliy''..l<.,no.i at ,uy r...,ucst. l,„t .oul.l lin.l n„>lun^. abaonaal The

1 stenHu.u .ui,sH ...l at,..r oporatu... a.ul ,l.o l.oy n.a.l!: a ,.,o,l e „vcry

., s sc, alt.T sur,H.al .ntcrl«ve.u-e with the pcritoacu.n. tor h.stanco
HI the pfrlonuauco ot a radical cuiv ol hernia.

'■^t''"'";"'t'iiiip«.itanrc.mditi()n as in.licative of interna! injury
IS a r,g!d abdo,m.n without any distension. Absence o.' liver
dulness wdl be r<.t,.rred to later ; it is not a sign ,o whi.h any
nnportance should be attached. In no case should a su.-reon
wait for Its development, or ,-efusc to operate because It is
not demonstrable.

When the shock has i)assed oh". tli.M-e is usuallv no diHicultv
111 coming to a condusi.m. but in many cases, 'espe.'iallv th^
more severe injuries, it is the wisest plan to interfere before
the patient is fu,-ther exhausted by loss of blood. The daina-ro
inust be treated in the same way as a wounded artery Is
attacked m moie accessible part.s of the body.

Statistical tables show how very important it is to operate
early both m these cases of ha.morrhage a.ul in those in whi,.h
an infection of the peritoneum may follow. There a,v i.ow-
ever. many instances in which it ,nay be necessary to consider

A.A

O

18

THE ACLTK ABDoMKN

ihv .lucMiuii .,f ..pcrafi.,,, iu appan-nflv I.u,k.!,.>. , ,„..r|,,.„.,|

cases : .m, tho vt-nlict in favour ..f „,M-n,tin,. sho„l,| T.ot l«.
put asuU. lo„ .vadily. Tlu- „.a„y ways mow availaM. of pro-
iH.nn« ; ,a.stl>c..s,a a,..l tiva.in^r ,„||„,,s,.. wi,h tlu- rvidcmrs

^^l ml. pu Mrslu.! rases aflonl. justify a.nl of,.,, .onm..! an
Htt(>iii|.t. lumover l.a/arch.us it may app<-ar.

WOUNDS OF Till-: AUDO.MKX.

I renK.,nl.er very Aveii wl.eu «v were tau.W,, that it was a
wrong pra..,K.e to interfere with woun.ls of th,- ahdoinen •
ai.l.n.prmte dressings ^n■^v to l,e apphed and we w.-re to wait'
... symptoms !,. in.portant tlnng in all these injuries is
oaseerta.n whether there is pen.nation of ti,e pc.riioneu.n.
' > 1 .yaMul exannnation of the part shoul.l he n.a.le under
< na.sthesia. L,.t the region bo painted with iodi.u- as soon as
the wound ean be expos.-d. and do not ...mplieato nuitters bv
doii.g an nnperfeet exa.nination either with probe or fin..,.,"
Cover ,t w>th a steriliscnl or antiseptie .Iressing. and ban.bge
MS nuo posifon. In eases where th.-ro is Inen.orrlK.ge from
u- paru.tes tins must be arrested in the usual n.anner. ' Wh.-n
the bieedmg pomt is not easily foun<l. it n.av be a.lvisable to
plaee a temporary plug in the woun.l. Explore as soon as
possd.Ie. a,ul so ,nake eertain of the extent of the woun.l • if

heperit..neumhasm.tbc>tM.,H.netrated.,heblee<lingisarreste,l
the wound cleaned, and eut museles sutured. Th- n.ost'
dangerous eases are not necessarily tho..,. in whieh the e.seape
f aWonnnal eonte.Us proves the faet that the p.-ritoneu n
as bee.i nuaded : they are subj.H.fe.l to operation without
OS.S ot nne. Do not wait for sympton.s ; it is bad surgerv
J at the operation the wound is found to exte.ul into tho
per toiioal eay.ty,. thoi, a n.ost ..areful exan.ination of the parts
M tlnn should be n.ade through an ineision of ad,.,uate si.e
.Shouk the pafent not apply for treatment until .son.e davs
have elapsed, you must be guiihd by the svmpton.s whieh aVe
present,, paying special attention to the eonditi.m of tlu> pulse
H'u s.gns of local intlannnation. It n.ay still be .uressan to
explore If there are „o symptoms it woul.l be best to keen
tu- patient under observation-for serious svn,ptom« have
cleveloi,ed alter some days in ca.ses of stab Mounds

I

'•^k^:

iiU-HAt'&iSt.*- <Ji

INJUIUKS OF THK ABD().\rKX

lU

Will

Fa makiiii,' tlK'.soo.\|i|.)iiU

If is iisiially possil.l,, (,, ,.x(,.,i,| tl

«»r\ iii(i>iuiis llin.iiyli llic alMlmiiiii.il

tliat tlic iiiiaioniical

irin III si

1(1

corisKli'nitioii.aM aln-ads adv

aiTaiij;('iiiciif of the imixl

I a ilirt'cf ion

abdominal

after (li'voloj, incut of
iiiun m

'•■s i.< taken into
>'eil in the |ilaniiiiij;and .'nakiM" of

ineisiouH. Avoid the iMi.MI,. lin,. if possible, Tl
KTiiia may iiiak<- I lie lif,. of

a '.ciitial I

isurabic and lii>4 ,su|>|iort a Imid

still the fiiNt consideration is i
opening' f()r the cxaminaf ion

en to tl

ma!

kiiii

le loiiimunity,
an adc(|nate

If the wound

the protrusion of jnt

!■< of considerable si

/e

ml permits <

.f

truded must be

estiiie. oi'ienliim. etc.. the parts i

saline .solution, boraeii

carefully washed witi

II o-

before tl

•••ill soluti(»n

warm sterilised

cy are returned to tl

il)ilomcn.

Wounds inflicted on tl
ieneral piinci|)k>s must iMiid

treatment of tli

sidered later. (

place. The herniated (

wounded parts aiul enlar^'eiiieiit of tl..

should then be no nu)re .lillicult than it

'r even boiled water

he (|U('stioii of

■sc parts will be con-

e you in the first

ontents will be reduced after repair of

ipeiiiii).'

deduct

ion

(lurijig an operation, where it hash

IS after examination

bowel outsid

If the ))owel I

le in e.vplorinir f,„. ti.

las

iU)t been compressed bv tl

■II necessary to bring much
eause of an oiistriiction.

for any great length of time, there should 1

small

• peiiiiig

The protruded parts must I

»e no distension of it.

repeated, for if there \>

•e most carefully ck-aiised. let it |

)L'

later it will be most comnioiiK

my contamination of the peritoneum

caii.s«>(| by sept ie material

111 when the lurniated part is reduced. |

carriec

n'(|uired.and sluuild 1

)rai

bi>

carefully sutured in la vet

>e avoided if possible. Tl

iiage is s<'ld

om

wounds l)y the surgeon. If the st

IS after the niakinu of

le wound should

in-ei'iilai

IM'rmit of careful suturii

lir 111

sutures of .salmon
When the wound

'iiver:

riit.

;ite of the j)atient does not
use strong interrupted

is adh

passing through all the lay
s are of longer standiiiL'. and tli

■ers.

creiit to the lips of the Mound, it

returned if its structure

tl

IS iu)t injured beyond rcj

Jirotnision
must be cleansed and

lere is a .se|»tiu wound with jjossibh

laii-,

W

len

in some install

ices little can ])e done bevond

gangrenous protrusion,

and making jirovision for relief

of

cleansing the part

question of excision of the whol

any constriction.

Tl

le

considered ; in snmo this would be the- best

e lu'otrusion will have to be

Ircatmeiit, if tlio
c 2

20

THE ACLTK ABDOMEN

"f |.n.,n>MoM „f ,„.. o„...n„.„.. vvIm, . „ L .'r^''''," """"".•UMe

th.- i.'ti-,.atii,K (.„■<•,.. ui.l rl„. «.n.,„l « ■ i "' '■""'">■ *-'^ ^"'PiiHf

•' W.V. ,...M,p..„...l. Al,..,. ,-..„ ,vu ' , "" '""■""""• ""■'■•""^"

-•-trie,.,! ^u, ,,:,'; ''v;i'"''''' '"'" ''*'^ '••••■"-

become -n-'t ;,,:," ,.V'"' /""' •""'^'^ "-"^ '--
n'suJt.nf; fn.n. ,, for,,,.,- oju-raticn "■'"■ *"^^'"'

-!"■;:;■ ;r.^;;.r:t'::--;--;-~

HU .. ,.on.r...l .n.„v or l.s. .v„l Vow " ," """ "'",""""' '" ''^' -"

r.-du,-,.o,, a,.d suturin,. of „,. ,„rN ,':':'r''' ''''''•■ *'''''*''''"'«•

strangulation JwU JHt u Jar-v f,.,„o,..l - . ""''' "I><Tatio., for

Gimlicn.ufs Ji^.amcnt " ""*'' ""'" "'" '''•••»^' divisi,,,, of

=;;«:t;:;';;^i,^:;r:!;;:::„,,, J: -■:'"- -S-;;?™^^

Gunshot wouiuk nf fii/> ,. i i

LVU'KIKS OF TI£K AHDUMKN

21

"•*•'"•'•""'••""">'"■ ".l..„MM-l.,nll.....Minju,v.l, TlM.r..„,avl,o
."Hny wo„,„ s ,n .h.- houH. ,1... .,...,.„„. ,/u,l! I... ... . , v '.

I.Hs n.on, .vasnn f..,- ur^in. o,...,..t,oM than in ..... ,, .„',';
suh.:u,a,M.,.us n.,,tun. ..f ,1,,. ,..,. „ j, „„.. „,„ ,h,r. .^v J.

t ra.k n th.. I.„|,., .low,. |„ ,1,, i„>nto,u.,u„. anv f„roi«n

'•••"..;,'l. to a.l,n„ o, „.orou,|. ins,.....,!..,, of „. . ,,1, ^
<-'U-nt.s n,..|,.,.|y„,,, sh.a.l.l 1... ...a.l,. ,|.,o„«i. ,1... ,,..,, ,7

::;;:::v';t ;'''""•'''''??'•''•' ••••""^-y-'h ;!:•;• a

g.iu/..-aii\ l,l„„,| or,.M.a|„.,| flui.l sli.aiM 1... wii,,..| u.-.v ■„ I fi

trader „.,.,,u,,„ ,,,,„.„, ,.,,,..,. w...:; '; ■^- ,t

unt.l.u.,..a ,,.sp,...tio,.|..s,,..v...itl.a, ,. ..,,..,. av..L;^^^:^^

<'X,u„„.at,.„. w,tl, .,..n|,s...| sali,.... Do „..t ],..M,at^ ,. .4^

H-g,i.n„.g at ,1... ..a.....,,. a„.l wo,!.,.,, f,,,,,. ,-,,, ,, , ,.^^.,, , > '
I .o.,...at,..,,|.asl.....,.,|.,,,,,Hy.tl..r....i|,,,,,,,,^
of t u- u.tc.t,,.,., a„.l u.a.Mpniatio,. of tl,.. pa,-ts .ill 1.. ,.„„',,

Alt,o„.h ,t unl 1... a.lvisal.l.. to foHovv tl,.. tra.-k of tl,,-

-•"'."' «'-- to ti... p..,-ito,u.,„„ i„ ,„ ,,,,,. ,,,i^ i,„,.i,,;„ ' .

n>qu.n. to 1.SUPP1..,....,,.,, ,,,,,,,,,, ,,^^^^^^^

<• o„ahl.. yo„ to .l..al a.l..,p,atdy nitl. ,J.,. i„l„,,., ,„,,,.,.,

a nu>st ..ascs. ,„nv..v..,-. tl... li,...a ail.a .-a,. a„!| l^nl

u-.„.lc..l. o„ a..,.o,.,.t of tl,.. ,la,.,..r of lal..,- .l..v..lop,„.„ 'f ,

1-nua; but rapi.lity of op,„.ati,.g is i„,p.>,-ta,.t. uulij C

surgep .vI.o has .,, .ha.| a «,.at.l..al\.fp,.a,.ne,. .;;:!:::
t-uinphcatc.! iiicsiuii may be bi-st.

22

TIFK ACITE ABDOMKX

•'"-i.i.f. I.av,r n m t. In^h'" "'!" """"''' '' "- '"^-•

-"..r...i ..,,.,., w..„.'l^ :;,;;;;;'''■ .^- ."-"iiton ....t o.wy

HHK-k n.UHf l-|.rop.,rti,.HtlIv«r.J', .r h. • • ' ?'""""' "^

<''^"'"'o""t .,1 .larnat.. u- i ' "'.":;'."•«•'•"' »<"""■« quickly

-v.-ral ,.|os,.|v s ,uat ! :, r^" ' '"" "' '"""* "'"'» ^''^••- "''

«•'"•. is vai,mi;i,.. Ko writ,' 1 '"""■' '" *'''' '^•"•"' -^f^''''^"

;;:f7-'nt:^ri:;:;:;— ^ ,,..,._

rio advises tliaf ill .,j>,i .- """'""f "> Hie roftuni.'

■■>..l.nlly,.,„„,,|a„g,.r ' "''"''""•ly <>""■> umil ,l,..y are

zt'""r'" "" '>■ i'"i'2u: """"'!■' """< »i»i..i.-

I\.fI'RIF;s OF THK ATJDOMKX 23

ii.ftjorilv «.. nu- ii.rl will, tl M„.„„. .lifflniltv that in a v.rv laix-

proportioi! ... th „Mo,.s on nhi.-h tlw... ^i.uu.U ..r.< r....,..v... u,

un.lor whuh .1 woul.l huv.- t„ h.. jMrformml," >"<•«' 1..,,*

It is m-c.-.Hsury t.. rn.pl.aHiHi. tli.- fart that l,ull,.t h,„„„Is „f
thrintrstn uro ..ft... «i.lHy ..paraf...!, a,„| a MNinh lin.if,.,|
to «l.. imrfs uii.h rIyii.K tl... siirfac,. woun.l tnav hv i..a.l.-.,uato
to nvfal their iiiitiihcr.

(Juii.hot wouikIh „f thr stomach varv very «-....si.l..rahly
aconlitiK to tlir nafur.' (,f the weapon, the .si/e of the h.illet
Its shape, the (listai.ee fn.i„ whieh it was fir...!, ete. The stato
of the ...gaiis as to .listei.M.m or eniptii.ess i.mst \,v taken into
i-ons.deration. The bullet may co.ituse the a..teri.,r wall pass
into the eav.ty „f the sf.m.a.h a.ul remain there. „r m„re
prohal.iy peiu-trate the posterior wall als„. 'J'he an^r|e at whi.h
It entered must also ho taken ir.to consideration, as the prol>.
ability of .lamaK,. to other parts will much depend up,m this
Karly operat.on in thes«. as in other injuries penetratii.L' or
possibly p..netrafinK. the intestinal tract is very important
iM.rgu.. and Jeanbrau ' give a series of 112 cases, 'in which tho
stomach was wounded by bullets, and the results of operation
arc shown as follows : —

When tho stomucli only was wounded-—

Operations within six hours
uftt'r this j)eriod
Wou.ids of stomach and other purt.s —
Operations within six hours

>' M six to twelve hours

,. after twelve hours

,, time not statwl

In these cases the opening should be a median one. mj.de
quickly and freely, so that the stomach maybe easily si-en and
manipulated. If escajjo of tho contents of the stomach has
taken jjlace, the peritojieuni underlying the wound must be
cleansed, the .stomach wound located and sutured, a double
row of Hufurcs being used. The gastro-colic omentum should
then bo freely opened below the greater curvature of tho
stomach and its n.aiti ve.s.sel and search made for a posterior
opening. This will probably afford evidence of its existence

' Bfvue de Chirurgie, 1903.

Rei'Dveicil

Iliec

))

4

2

4

13

1(5

2

It

o

11

.'}

5

lii

sim^»'^m^^:Lii^:m.ti&^

■^w-)&

tL'.':;:,';!;::;',,:';;;; -' .™.» ,.,■,.,.,„ ,. ,

; """•"■;■■ "■ a,. ";' '" « '"""'"■ ' .• o

ti

•■'"""".u, ,,,io,,. ,„,j, . '■■ ' ""T are ov,.,-l.,„k,.,l r

-r"s:s5SS?- ^

"Hide. (l(..|,if,. H, , J"'^ 'o the Jiv,.,., 'rji.. ., ;, V ''"■' ' '•ucet ami

„,, K'at.oi, i.siioi will,,,,,,

J'"' tivat„u.„t of fl

'^••^'^.•">-'i conditions d ..s Z''' V"'"'"'^ ""^' "'" «<'.H.r,I

'^"^'•;1'"« to tlH. position of .; ^'"''?' "''■"'•• ^""l uill V '

;:,;;. r«" ";-'»■'■■ ■■ -,;;,,';;:;,'„.,';-:',;-

iMx.' iMvn. (Inunag,. miH ;,., uvrv^-nry "

III <,'iiii>li(.t Mounds aii.i . ,ilw ,.» tlw I,, .. ■. • I

■;!;„;::;;' ;'»» •- ii:' /;:::,.".;;■ ;;;:' :;::;;

<»..>.. n.lood or iHl..-..,anH..I Ih.i.l .(nVI. J.as I.,.,.omh. lo,.ali..d

"■';";<''".i..iyli.>l..,ninlli,.„.,ll.,.|outh,. ril... i, uil

::'::.;::;;r::;;;;,';r::;:;i:;;:;t;;;;- '■

-i:'l;:f :-:;;::•;;;':;;;;:;,, 7,.,,:,;::;:;::-;;;:

;'"■ "'"'^'1 ""'""l i" <!•- liv,.,. ,„„„ I,, .,v,-,l,,II,v' ,„„„,.
111 l)ullcl wounds ot the lixcrln.fl. .i..f.,, . i

-ily found an,lan....il,,.. it .,,,,,,,,,,,,,,,,,, ,^.. ,'•

^innild a,.,H,. n.ul. tor any ,...,i.a, of Ho,lnn^ ,r ;^^^
liavc l„rn carried in Miih it Tl„. ,i ■ '^

Wounds of lh. portal ....]. „.,,,„, ,„,,„ , ;, .

•-.a.uM,u....od,a;;nJi;;;::f;d';:;;:::',;-:;;;rt:;:^^

LT)

'J'HK MVTK .\l{J)<)Afj.:x

"""■ "^ t'"'',. M-av. ■ ,, '" -•'"-'''"•I'I'T Mi,-.v I,,. ,,,,,,,,,1 •

;;"""7-' y. Z,:,il':z,.:r '" !'"■ "'■■■^""■" <

'"'■■'■■ »'''ii'™ii..«.-...';l,,',;,: "'"■» hi-.':.?:

•-'"''' -Mn<.isi<.,. , J,,,, -^ '- '•<■ .•.•.m,.,l out

;;;''-'^'>'-n;aou,.o,.,.o..aJo !:::;::;,;'•'''" -•--

"■, •"""""' of hWWin. ',.'": ''''''••'^'^-••'•' --.nut of

["■, •"""""' of i.i..<.win.\;;;;,;Tr/''"'"'i^''''''''-''"''t<.f

••n 111,1 \ |„. sUCCCsvflil -.,1 '^ ('l,l( < s,, . p .. ,

, ''''•'••^<-<'f|.rotrusio,.of,lH. ? ^'''•''■•''■'•'J''''v.

:;77'Hss^o„M J,,Jjf''^---ands„H.a.^^

r'f'r;t- ;;;,:;::--;';:■ I-:',-.

IS near. J'uai.d l,\ ,|;n„a,L'c to otii,.

organ

Ii<'li,.n;,ti,. fi^ '" "" ■^'nall ..,11 .,„a ., ." ;"'<l»ia,i)i„.

I I . ■„ •'-"I "I I lie ('|iiir;|s

'•'j.Trs. |,, .•i,s,)

nca
"iiiiii.

^

IXJl KIK.S OF TFIK ABDOMKX

'",:'■'■'," ""'■>'inMl |M.,f,„ai,:,i,s ,v..iv

f I.^il.Mr.,(„Miy w;is ,H.ir,.,ri....l. il

'"'""' '"kI sutiiicd iiiKl then K

i ;r:;:;;.:i: ::::r::t;:i:;r El' :■.:';;: -""••: v-"'""-

t lu),s(.n to giv<- acc,.>,s to tl.c wound '

:;:d;;: F-^ '-..:''i:;:::;.:";;r;;r'

'"" "•"it <\IV tllC IllO , . Toils In ;

ffiisoii f,, t'iiii|< tliat a \

Ml

'•""^- In iUiy case, if there i-
f Mils organ is i>lee,|i„,r. it ujll

;:: ;:;',:r;;;:' '' , :""' <r" -"" ^'"""' -^- 1; „ ; ■

^<)l\lng the leiial jm.Kis and jxmiittin.r „[' esen.e ,t .,..;

■o .lr..m„g,. „NI ,l,c.„ l„. ,„...,,.„,, Sl,„„w' , , . „

x:.r,.;;;:r't";™,:.::"";"V'-;- r""-^-

;::'t;rrr:;;,i:;;:^:, ;::;.'''•■--"-• - ->.»:

H..„,i„ ,,f ,1„. n ,„„, ,|,,,„„,,, „ „,„ _ „,_,

o tJ.o hody ot the organ and does no, involve the vessel '

Hiiiituii

I'tmv nf I'anureu-.," ]i. .-,:.>.

2S

Tin-: ACITE ABDOMEN

i!

111

i

I

^"-:;;:.:t:::i:;i'':l':,:-^r;;r;'f'v "■'; >

'" ■■■I.- ^"v;,v „ ,„i,.„i„ , , „ , - - ""i"'-'"iy l'""-'M,.

"■«■'« "" '- ...■.• .1,: .':,;:, ";;■;;";"

::!'™:::'';r;;;:;:;;"',';""'''''T'''"" •'■"-'"''■'»

"■"■■"■I i» lin.H r:':^^^^

>4i;:;i':;,:^::':;;;:r;;;;;:::":;,'r-'^-" ^--r.

liU" ..11,1 „f tJ|(. loucr is li.ratnicl nwl ., |.,f 1 ■ •

:''■"■'' "■''■-'-■"'''"•■■-i".-^ll,;,T;;:;r ;""■

r-:;ir;::;;::;:::i:l;-t;;;:!;::;::i: :-"H^^

;■"'■'""' '■.'■ i-'K •■. "lit i„ ,1,.. ,,„ , . ,„,,■„,,"""■ "'

IXJrHIES OF THK .\BDO>rEX

20

of the upjMT end in the hiaddcr ; (2) impluiitatioii in the wall
i)f tlic liiri^f Ijowcl, cu'cuiH or siijMioid ; (.'!) iicplircctoiiiy.

Ill (1) and (2) the opcrat ioii-^ ai'c similar in tcclini(|ii('. 'I'lic
lowci end must l)f closed wit h a li;iat uif. 'I'lie iip|)cf end is slit
so that it may not contract too much aftciwards. The po-'tion
of the opening' nnist he such that ii> tension will l)e left after the
sutures have heeii put in. In the howel the letroperitoneal
surface nearest to the meter will he ^elected, 'j'woi-ous (4 tine
siitui'i's will he necosaiy. the inner mw takim; the suhmucous
tissues and the outer row the musculai' and celliiiar co\<'rint:s.
It has heen recommended tliat the hiadder wail -lionid l)e lifted
u]> and fixed to the ])elvic jieritoneum w ith a catgut suture, so
as to prevent anything' like dragifinj: on the line of incision.

K.xcision of the kidney can he easily ])erfoTin( d. and ma\' he
the oidy possihie metiiod to employ on some occa>ion^.

Wounds of the i)iad<ler are the re>.ult of gunshot injuiies.
punctured wounds inllicted liy pointed in>trumi'n{^. or wounds
inflicted l)y a surgeon dm-ing >ome ahdominal o|)eration.
(iunshot wounds inflicted in warfare are most sei'iou>, liecause
of the difficulty in obtaining adcipiate treatment soon after the
wound has heen received. The\ reseml)le in this res|)ect the
intestinal injm'ies. AFr. .Makins, in liii, "" K.\))eriences," p. 457.
found that "an uncompiicated jxTt'oration in the intri])eri-
toneal ])ortion of tlie viscus was frecpiently reco\cred from.
Wlien tJie ])erforation was at the l)ase of the hiadder. lio\\e\ti-.
the prognosis was very liad. and. as far as I know, not a >inLrle
patient escaped death. The increase of risk in oi extra-
])^'ritoneal wound of this vistiis is indeed \ery gi'cat. while an
intraperitoneal ))erforation may In- considt'red an injury of
lesser severity. ])rovided the mine he of normal character."'
" Drainage l>y a catlu'ter tied in ])rovetl svorse than useless.'
fie considers that a supraj)uf)ic o])i'ning might he hetter. l)Ut is
not liopofiil under the conditions which olitain in wai' time.

There can he no doubt that in ordinary life exploration with
the provision of drainagt' will ])rove the most successful.

The accidental womids are most vonunonly the result of
falls on some })ointed iiistrinnent. such as a spike in a railing.
the broken leg of a chair, a stake, etc.. when the injury i.s
inliicted below the puhes. through the rectum, vagina, or
perineum. A htab may reach the bladiler abt)vc the pubes.

:io

THE ACUTE AI3DO.MEX

" ll"» i» ii.,i i. ,„,,,| .,,„ , .1"" "' ""■ M,„M,.,. ,.s,,„„„|

" ""-.-;.■«■,■,.':;:;■;"■ "''-' ..„: ■

I, J" '''■'■tioii of til.. ,1,. ■ |>i „...,.,,, „lll

•^-"■gi-W wounds of tie M,,^''''''^^^^^
"- P'"-'t day tJKu. L-v ;: "r '■^: '"""""""y -- at
"."''^■•'"•'"^ <'|HT.tio„. T . In! '" '"l>"'ofoMn- Mas •

; ;;;;''7-'^ op.nin, a ll!£:;;;;^ ;-'7<' - .>'^- a,.:

*""" <'t a, tumour or uvWi ■ ,„( . ' '""''" •''■'^^^" "P in

'"" "^'-"Pt to op,.„ , , , ;, ; ''''".^•''••^' '""- t''at iK. do

^^'ioro operation, and .iu. r^o 'i '1'''''';''' '''''- •^'" '"""•.sion

''•''•'!- '^ - i'H'ludcl vit ;;■""> '■^'"'■'"">- - ^'-"o
;7;'-- muc-h pain, and ,, ■;\'^''''^'^'^ "- acid.n

car..fulsc.ard>. In douhtful (.., . ^^""'"' •'^"^' '^'"-'''1 lead to

;;^y ^'- biadd... wii, bJ : ;:;;;; ""J'-'-" '>^ -iin<.so,utio,
i-be passed into a ''-btfu:;;:;!':;;:;;;';?^.^';;- -i;'o ■ ^,-^

I .-.->■,--■•;• ...^ •.■•1,. ■

:i'i-b^;4t'"

ilr'fc^

■'A -'<!..

-^^

LNJIHIES OF THE AHDUMEX

31

hhuUU-v) l,t. nuuU' to t..u.l. a silver catlu-lrr i,itnHlu....l i,, ih.-
u>ual n.a.m.T. 1 havr mH with lln> ...Muplicatin., i,. Umv out'
<>t ..m- tl,„„san.l .a-cs ..f ra.lical .uiv nf inguiMal licniiM

It IIh' un.uHl :s ;.n iiivj^'iilir en,., it sli.ail.l l„. trii.unc.l „,,
:""! 'I'«' »''lj:«'s l.n.u.uht to-.-tluT with a n.w „f sui.uv^ „.'t
niva.hn^ti,<.Mn.cn„s„u..nl.raiu-. As thrx- hmiia. a,v ,.tt..,umt
.•^ncm by i..T.tn,u.,.n.. they aiv .lillin.h t.. .hllcn-utiat,. In,,..
th<' ci.lh.lar t.vsar i„ whiH. th..y lir. aii.l ..nthin^ hkr a .!,.|i,„.,|
niaigin ...ay !„■ trit to ,..ial)lt. you to iv,-oj;„is,. it Th.-v uv
also at ti.„rs, vm thin. a.,.l ...ust I..- . aivfuliv sutu.v,!. '\t„.r
Ih,. l.la.Mcr h,i> h,.,.ii sutun.,1. it shouM l,.> mi,„.,.,| ui,|, ,|,,.
uvvk ot til,. ,sar aM.I the ojuTatio., roniplrtnl l.v the ..ailicnia.'
method tavourc-d. '

TJ.c ut..n.s is raivly n.pturwl l,y ai.v fo.„, of <.xt...„.,|
violciuH.. I'vni whc... i„i.gnan,y i.^ far advai.ci.,!. hut when it is
a vi-ry srrious j.robl...,! is iHoscntcd. The ch.r.jrtT is ..n,,f fr,.,„
"MtiTual J.a..no.T]iago, Mhi.'h cait oulv )h- Hurk.Mrijv cailv
oiuTatio... This is truo also of a ^unmd. and iu hot), th,.,;
must h.. „o driay. Whoa a prrgnant wo.uau has r.r.-ivcd a
k.Hv ov(T the ab(h.nu.„. the amount of dauiage to th.- uterine
wai will vary c....si.lerahly ; sometimes it is vrv ••xt.-nsiv,.
un<l then, is no eha.iee of saving the patient unles's the uterus
IS fm])tie(l an.l afterAvanis re...oved. In the ease of ruptures
nt hn.ned extent, wh.-n' thc-re has !„..., Imt sh'.rlit eseape of
amn.otie tiuid (a. also in wounds of similar in.p.atanee)
strong sdU sutun^s or .'atgut shouM he passed thn.ugh the
nil thiekness ot the wall .h.wn to the In.ing and ti,.! others
.en.g intn,du.(-d l.etMeen th.^m to elose the peritoneum The
blood-eiots a.ul tiuid should be eleared awav an.l the external
w.mnd elosed without dniinai'i-

Jt the f.etusorm<'nd)n.nes are pn.iapse.l. tJii-n it is advisable
to plaee these within the uterus a-id if the wound is not a lan'e
one suture it. leaving the f.etus to come awav per ria. n„tarahs
Jn later stages of pregnaney wJn-n there is j.n.iapse .,f the
f.etus. or tlu- M<jund is large, ren,l..ring suti.ring unsafe it
w.ll bo best to e.npty the uterus in the juanner .■m,,loved
duruig Osarian seetion. (Krasionailv after extn.etion' of
utcruie eont.-nts, Avhen then- has be.-n pn)lapse of mueh or all
of the fa'tus and membranes, it may be jmssible to repair
the opennig; but tla- bleeding .nay prove difficult (o arA'^t

'^-''■'^:i^ il'A

HHBTB

mM

33

'''^'^' -^^-^TE MIDOMKS

cases ^v/i,.,v ,1, , "" P''"«'iil . |„„i ,,

"^r-"- "'^"^ "■"■"-■.■ '-:;:: ;:;;rr

■^ '""-f iniiK.r,.,,.. I "' ""Mh-

=''-s" S^S'-F ™""^ "- •■■■■'■

^'^•<' hours uUo, ,„, ■ " '''"l-'n...,, vas .si,.),,/''. , ' ",'"' "'"' " '•''«-

*-'"''"• <■.-.! uua.U, Z. '] '•"'"•""-» tour ,;' '""•■"""• AIkmu
was s,n,„,,i. ^ ' l-'.»...n...,l.. ,|... ,„.„„ l ' "•" "^••'-1 and

"•'•'''''ii'nlu.fu a ',,'''' '" ""■ '""'•'li.'al . " '■ '" ""■ ""<-''ii.'
"' '•^" uj '^ '"'•;'■ -1 /..«•. I..v„ i, :* '■'"""■'-1 -lu.,„«h "

"'•'".•,.,1 „„. s,„ ;, , •^'•^"■'■"' >..>,.,.„,, „, ' "-"•"<..• n;.ll ,h,. u,.„n.i

r'^- , ''"'■ .•.■'"::!;;;;- T'"- r" --•':".:.:■"""-" --•

foJJap.so due to mien-..,! i Wfuneiir,. ^f , .,„ "^

■^w^.

'N.liniKs (,F Till.; M-.rxvMKx .^3

^>ll«'ll llic iiricnifoi- li 1^ I. ,,l

•">• ''.-^mI! ::,;;;:::''7;;'''''-^^^

"^"> ■". I m:'*;:;:, ;:■•';::;,;;;-';;'••!';'■''• ••'

'•'■-■vix and ,L „ n^ "^^^^^

'''•'^..■.•i.onc.u;;;;: ; ''^^ ''''•V''-r''''''''"^^

''''•''-v.'s.suturH,..i„.;,,:.'V7 '■"''' "■'"""' ••'-'I-

'-"' - 'ou- as ,..ssil.|,. : -(IMW 1 ■■'■''" '^''''''''^
"*"''' '•■*> '-•..a. li.a.M,.nt M i "'''"''' '"■""'"''^

(:-') Search tor tlu.ut,; ' > ■ ''''"'"" "'- ''■".'I-.

--•"<<■'•..^,:,,\:::■'^"'''''^'-^-•'-'u. ami .livid,
't-''-^- wit,; u;::,;rz:'^, ■;•;;''- ^

^.«lc' ..car attaclimcnt ■,,„l ..„ ' ' '"'" '"-'"" '"i ''ft

[""''•"■'■'-•^-'^''-'-adli, ,!^- ;^/ -i.aM.l.livi,lo
'^'»-<'".« vessels tha, „,av have- .t, ' •,]. '" ^""' ""•^'

A.A.

■"■•p. .V.J; lUr„K,a, -Uilii.-ult Ul„nn.

D

■' -.J'li. W.«Jp:-llK«3i'-'» "5t«.*!-

.11

''■'"•: \<'l T|.; \|il)(,.\|,.;x

o''-:4r..:':;;;::;;,,:'-;i;V'';, ■' ■■" ^''*

'". ••iitiixlal,. ' III iiltiiiiir ..

'"•""■"-» "• M... loiiiii. .■..„(i,„.M ... I . .; "''"'r ""• '"'"""■ "'"'•''

(lllllJ..||l„.|„..,., ... ,.- . ■ -'^'" •"-" I'l'' ilV.T;,m. ,|„„,;.|,n ,,. ,,-.

""•"■"•"• "• 'I... i,.iii,i, .•,.„(i,„.,u..Mi II. ' r '■ '"'"""■ "'"'•''

<n"K;--y...., .. .. ,...,. .•.n.-;:::n;^;.:,:::iir /■':"•; '''''> - ->':'

>.i.N> III.. |„„,.,, nioiialiiv I, ol.i ,M,...l ,.1 '"""'"•'■• I"' ''111 . .tn. I
"•'■' '••'" '»• |..rfo, „....,. „- Vli ;■'','''''•''''' ^''"'""Hn.l „,M.|..

""■'""•"' '" ""■ '"H^'niM uil ■„, . " ••';"''''•■"• """ II.- sal,.,,

"•■' "■""- '•■■'•--f:^-i:.;::;::::';:;:',!;:::.r

'Hi \l M \II,

i..\m:ii.\.\i. u(iiM)

vi'i:'.i':,::;r::.:'"''-;;' -^ ..i".^...«.i,..„.„ ,

i,,,, ' ".t.»..u.»l..f ,l„ ,„„i,,,|„ .,^,

-'"'■"■'■I .'i.:,;ir,i ;'■,"'''''',■''•> "■'""■■■'-■ "-

l..«;.al ,,,L Tl,„. ., , „, , '""" '" I'"""'" I'livsi,,.

v.M.„»„,„.i,i,ii; I ;';,;"■" r '•■■'"■■ -1.1--.1

■""'■-■. ...1.1 .1 ., ; , '"""■'•'■""■;" "'■•"l>"''l "- .' ...ail.-f ,.f

:,:; -"■M;;:;;;:;:::s;;:;3::.;:r ;:-","";'

tile ojHTalioM a,ul not f,. T ■ ' """''' '^^' •'-'•'•i»>ed to

»" *a< . tlu. n.s, ' . '"^"'•■^■■.""^<'^' ^"''M-'Ms unwilling

TI!\IM\TI( IM I'TI UK nK TIIK \|s,'|.:i'\ :,.-,

u.. I

ill a iMticnl uiiliniit (Atriri.il «,,iiii.| (I'Vj. I). All arliliri.il

iimis \\.ls,.,|,,|,||s||,.,|.,Hl.| III,- |,;nl,||l ,1,|M\,.,| (Mr ,. IMc.hlll . ill

til<t hr dill uril until

rocctioii .it ilii> .irlilii'iiil

iiiiiis itiMJ ciiil to • mil

t llt('roini|>liy \\il> ilniic.

lint t llr M'Cnliil ii|i(|at inn

Viis nut snr\ i\fi|. It \\a>
mil iiinj^. Iiiiwfvcr. Iictuic
a -iinilai' imm' canir int<i
tiic iiu^|iit.,l : thi-. iiiur
Ci'iift -nlmv<l the rent i;i
llir jiiit ami (■ii.-.nl till-
t'Xtcrnal uuiuhI. 'I'liis
pilticiit niailr a iKitcrt
IfCdMiy. 'I'hr >aillr

MlfJ^rnll \\a> tlic lil-.t tn

<i|)ciatc for a rii|itun' o.
the sjilccn. and .Mr, A. ( t.
Mackfllai- did a siniilai-
opcfatiiiii till- a lil>c iiijmv
ill a sfcdiid case. Sir \\ .

vii'a.' i.pnatrd tor intiaprrituncal rnptinv ,,t tlir nrinarv
l)la..,.rr, ami ivpoatcd his .siinr^s in aiinilirr .ax' lu.. luniitli's
later. TlirM, ucn- the lirst i.t tli.ir kind i,, u|ii,li M.r.rss
Mas ..htanifd. and naturally niadc a deep iinpri->siun on tlic
pio(i's>ion.

.\ tahic ot al.doniinal injuries admitted to all the London
In.spitals uhieli pnl.lish statistieal reports is perhaps of some
interest and is as follows : -

St. Bartholomews (I.ST:! liMMi). St. Thomass ( KSfMi jiMiT)
Middiesex (l)S7:{ I'.MU). rniversily ( 'olk-ge (Ifs7!l l!M»t). \V,.st •
minster (Issti |!M»:!) .- —

Situ j, If r<ilitll>:i()ll iif !/,!■ iilidnniill

With iiijiuy to kiihi. y .

aliniciilaiy iMiial

llMI'
s|i|c(U .
l.lu.l.liT
liiescMliTV
• • iiliii'lll iiiii

ii" i"iitii.ti .,| inl.-t ■VIM,!

)>v .I..1;m I r..|i ill ih,. |i|.,t Hi.(, -liil

I 1-1"' '■l"l^ltl.iii li)rtl;iuili;itir lli|.tmr

^>t. Ill.il,,;,,', II „j,jt;|] .Mil., .11111).

I'.-lrr

■4 7

4 .-.

M

<».-.

'» :!

I) 1'

•j^

1' .',} I

r*^

:i *f^

3i(

''■'"•- \' « TK AMDnMKX

K <-"H//« ,,/•//„ ,il„l„„l,,l

l'r..|«.|fl..Ms: \..|, ,„.M,."|,,,l,„i,
l''lli li.illhi;

liiil.iinitf
• ""(.'Ml.. ..I li,|.,,ii,' iitt.rv. ImiII..|

'I'llis ^rucs solll

IVr ,,.
Ht
I II
.III

Til

'<•••. ;:n(.s sonic II (M of (lie ii.liii, .

.■.■'::r:;:::::;-'-:,;^;;;:r::;;;:, --....-.».. ,,

; ' '• "--„ ■,.,;,::;;,,;';',;:;■■'; ;-;

''■" -V.V n,|,i,„vs .., ,i„. , c,;.,,,; , ' ■ 7""^ "' "'

"■tli""l ..|...,„li.„, : ,|,is i, ,villHi , '"»■"■' '"■■

;;■•""';' -'-- ■■- :■■:•.;:"! :.:z',T::r '-

II"- IIM.-II,,,., „„. „„„| II ., """-I "IJ.lii,,., „

' l«T ■■,1,1 i,,„v,.i,,l. I,„l „„|v ,,,,,.,. 'I'",'"" 'I'.'lar,.!
»-.-i"l..l »ili, a l„,..| ,i, ,1- ■ „■ ;""'■'" ' "''"'■■■"

"-"^ -•^'>™^v;;.:;;:;;::;:!,:;;:;":,::"t''^'''"'

♦'■<"" a nipturcl l,ow,.I or other iiitcni-.l . • '""'''"'«

^-^t^voornu.n.oftlu.s.i,•rr;f;:^

^'^■••^■nK tli.lu.i,s also, or frac/un. of ,,;.':' X:;/:r''

'>;;/."-vi.i..,.r.a,Iy..m.rs,h.,r.atc.st,,:L':,: •■"■'''''''"
J-;>'-;wl..tlii..U.ur....s,rc.su,,,ar..,H.,.. .1 ,,

•-'nu,i,.„.l a ,™al of this section of ,1.. ,:;' r' "•'"'
'"■'"'■'• ^'"' •■••">')...nc..nu.nt of tlw n.-rio I " '"'^ "* " ''"^F>'tai
/;-''W. .,n the'- Recollections, i^:;:;;•^'''''-''''^H^
about IS,s<». ' " ' piial .Sui^eon. vvritti.u

This

' l"n.cT was writt<.n hy a n.an of enunence. an.l rcc

ouiit.-

k%

/Mim"

THAC.MATK IMITini.: (iK t||k \|s, |.;|!a ;j7

l.iH.x,H.n..n.....i„,hi0.r U „i .nr.rn . I. ,,„„., uMnn.u..

rni.lii.j;. I., ,|„. .H.uunt „» niur.. il,.,,. .„„■ ,,„( m I,,. I'l ,.;,„.

;;'•;'•;'' ;7'"'''' '-''•'•■ Mit..>.M... im. .W.N r.MM,i. ,n ,1... ..()•....,

'•" '';"' '"• ••l'<'-";l '< -.•..,...1 ,H.„M,. ,|M. ,|H. M.jurv ,u

.\nn,h..r..l,l...h,mstl„.v.riuu,way>,n whirl,, ,,at„nt,

M.n. M„i.n..l l...t.,n. ih-.y r.nu- .u.-I.t oI.vtv ..,,..„. ',,.1 ,|„.
'''"•":;''•" l''"l .... «l..rl, ,1... .,,■,..> „| ,1... i„,„rv f.ll I, ,.

<''...|..l.'.l l,.,,M r,.,.,.r,U nt , ,,s... ,., 1... InU.Ml in I,.,:,,,.:,! ,V|,,,r,>

t .<■ hnu-y. tUr linlrsl, M. ,!,,„, j,„„.„„, „„, „,,, ; . ;

Messrs. Wvrry and ( ;uis,.,,,,j.' ' '

(',n,s,s „H,I S,ln.,liu„s nj .s<m,r Inhrmil It.,,, Inns.

Itmi over ill si led

Kickfil li\ Jiorvc

. iii-lii'd .

>tlllilv l>y liiiiviliy oliji'i'l

Tall on liaid iilijcrt

Tal! of wrijihl on mIiiIoiiu'ii

I'all 1 1 Mill lifJMlii

'"'"•.' <'alls.-;, |,lo>||y Mil
llllOUIl

2

1

•1-

- t

l.i

II

s

t;

~>

-

4

1

1

l.i

1

;

-'I

I't

I )
II

ti

-" •"*" r-\ \i\ I.;.-,

' . I..>sil.. oaMv,.,a,,ulu..vH.,,,a,.,..Mli..|..dvM,u..i<
••> >li.-tnnr wImH. ,.ai,s..,| ,i... injury, ti...,, m,,. .an niak,- ■„.

iH:|.n.xunat,.,u.ssas,o,l:,.o,.,ann,p,„n.d.r.,,, i.: :.,;'

ov..tl,isan.a«,v<.sn.o.s,.|,,v..,a,.,....s,,o,lu.,|a„.a^...|s,n,.,ur,.
.... .nnst not ..p.-t to ,i„., ...al ,i,ns ot h ,..,, .j !

^l^..l. tor then' niav he none 'I'l.i i ♦• •

II, • ""..*. tills iv ,,t iiniioriancc tiom i

•-•''-0-1..P.I asp,.H, fo,. no, ,on, a,o a jury. J.th ,,.; J;;::^^^^

!>.»-.=,: ;;..H. ,,{.[:, i;.,y„l S„.„.iy .,1 M,.,I„.„K' f.,,' Ijlll!.. ,,(,..

38

''''"' A' TTK AMDOMKX

"■''''■'' "PP-'arst.. 1... almost 1 1

•••■fused tr> ||(.|

"flicvc thiif
he Kilt I

'" illl ill)(|()|lli|l;,|

'<■ prerogative of

eoroiiciv

JIIIIL',"

'•'M'''nv ..f.iu. .,.,,,,,,,.,, ;;;;:|;,*;;:;';'/' "-"-i i.n.,i,;,.e.i a

'"• "'■■i''l< of the ku-U
"J-nes ,t is a.lvisal.l,. to follon-

'l-n; - "' -"' ''™^^.'w ir:;:,.;:;;:;;;"-'' , ■"

i:, :,.:;;:;;:;;;: ;":'V:;^ '-'. :i.™:^ r;;;:

""K'lK'arefuilvfordiiliu.ss.

"''"'"• '""' ""■" ''^aini,,,. flu.
■'"''-'■'■'nhisis(ixe,|ors|,iftin..

^--■'.1 or lo,.a|. an.) tC u ,o ' /r",''''"' ^""'' -''<'<''<"■ i< is

'«'m|''''''i(inv. '* "' ""■ I'"'^'' aiid (!,(.

, '•'"'•"'<■.•. tlu> ,,,,,i,.„, ,|,„„,,, , „,.,,^.,,,,. ,

(.perat... ' " ' ""''^^^ '^ '"'^ '••'■'i .leeidrd to

HAI-MATIC Hri

TIKI-; (,|.- T,,,,- IxTKsTrM;.

n.l,.,,, ,„,l„. ' i V V r ,"""■""' "■•"""'■ ■''"■■■"■•I

,. '<' 'leute al»(|o:ii(.|i

<liseas(. fi,,.,.,. jj^ ,|,j

In the jKTforatioiis from

"-eas,. nuTc ,s the initial - nvritoins,,, - ■„ Vl """^ "•""

I"''-»<"-'<i-.KMl.ielM-orres,,o„dsto,l '' ""•""'"^ "^

*''--''ia'<'lyfollouin;, : 7'''>''''''''-y"M..^^

;;'^-oniu;eseap..,?i„,.Jr,^- --^

f'l.il^ IV..I,nl,lvi ',1, , ■'I'l''"" I" !"■ I"'>1<- nipi.llv

is u,.pr,.pa„v,l to,.,,,,,, will, tl . 'i' / "'"'''■•' l"''"""«'-»n

i-<-...L,.d that', • «::'''-''^*''--:'-"- Wl-it

•■'' III ilhout od
is a, •• period of rcjK

IH'reent. of these , -as,.; ti,o,,-

'-•--■Hsnes,n.p;::;:,s/;r\;:;:'ir^''''''''-'''''^^

"--■l-'-'"sw,tl, tl.esan.e "s t Tu "l''^''"'" '"" "•■'"

M'vesal.storyofehroniein : ;:; ;'^,' ''''T

III li.e slomaeh. '^ '"' '' "■'■''"' ••>'•"«• pain

WillMViranlfo the symptoms uliiel,

"I'll li <»i, Jiu- suhjeil i(\-

rr..iBrp^!^-.

TKAr.MATiC lUITlHK OF THH VrscKIJA

3 'J

variDiis iuitliors. uiul it is (•()m])iirativ«-ly easy to lal<c a scries
of casfs aiul analyse the recorded symjjtoiiis iu <-acli. 'ri,e
result oI)taiiicd will l,e fairly accurate as rej^'ards tlie ohvious
luaiiifcstutions of the injury, such as shock, vomit iii^'. pain, and
l)erha|)s rijiidity. which are common to nearly all injuries iu
which the viscera are damaged. Tli. ve is. liowever. such a
dilTerence of ojdnion l)et\veen those who e.\an)ine the altdomen
as to wliat are to some com])aratively unusual signs, that little
reliance can he placed on statenu-nts which vary so greatly.
Vet these minor sym])t()ms may l)e most \ aluahle with a clear
history, for in all. 1 it-peat. it is inijxtrtant to diagnose the
lesion as early as possil)le. hefore the onset of peritonitis, and
every sym))tom that may l)e of use in i)ringing ahout an early
tliagnosis is of importance.

I do iu)t propose to consider tlu^ value of all the individual
synii)t.mis in detail. .Air. Berry has recently done .so. „nd his
conclusions in the main contirm those ex])ressed l>y Mr. ,|o|,„
Croft and Mr. ;\Iakins. though founded on a recent and therefore
more extended review of the subject. From the ])ractical
l)oint of view, we lU'cd not consider those cases which are
admitted Avith intense shock, from which thi^y never rallv.
The others can he arranged iu fairly tyjjical grouj)s. as they
l)re.sent themselves in actual ])ractice : —

A. In the tir.st of tlu-se there is shock, vomiting, acute
abdominal i)ain. with great tenderness over the i)art struck,
and board-like rigidity of the abdominal wall. All these
symi)toms are present. l)ut they vary somewhat in their
uitensity: at one time shock is the main symptom, at another
it is the pain, and so on. WitJi these there should !)<■ found
a certain amount of localised dulness on jjcrcussion 'Phis
group forms about oO ])er cent, of all cases.

MiLTri'i.K l!i en i!F.s ni- vnv. .><\i\i.i, iNri.sriNi: : Itrrri nr. m-
Mi:si-.MK.iiv : li'KSF.rrioN : .\n A-niMusis. (Dcjuli six .lavs l;ii.-r.) -
\ stal.lfiuaii iiK.'d 24 iMJmiltcd on .Viiirust lu. isiti'. siillViiili: tn.iii ili.'
ctT.'cts of a kick in (li<' alidoincn l.y a lioiv,.. al.ont liall an hour .■arli.T.
lie was rc.civp.l in a, very collaiKscd state, l.nt lia.l not voinilc.l. 'Iho
patient was a man (.f sli-lit l>niM. sntTcihi}.' inii.'h i)aiii in tli.. alMlonicn.
His tare was wliitc and anxious looking, and liis |)ulsc small anil fcchlc
Hclow and to liic I,. It ol tlie iiiuliili.'iis was a l.niisc. not i-lcarly d.^liiicd
wlicio the hoot of the hoise had straek him. The utMJon.en Wiw
extremely liar.l to the toiieli. somewhat distend...! ;iiHli!n,linh!,ss. Thero
was ('iihu^ss on ix^iriLssion over llie front of the ahd..men. < lear tirino

-^'r^^w^s^^^-z^fmm

ili

4n

«as wiili(l);m„ i

THE MVTK A

HT)()M[-:.\

Vdlllll.

.\( ••{

'.V •'ulliitcr.

P.iii. 1,

111.

flfv.d.

t<'n(l<T, llHMliiln.
'ml (lid ii„i |,n.,„i,
lilt

»' Mas

-»'>u iiUvr ,1(1

^lill siiir,

'lissidli lie

• •Miiy )l

J^vvi,hanvionsla..,..,„a,as|yi,;:,.
■'l'<l"M...n was (K,.,i li,,,

<'OIIlIIII'II(.<(| )

•'111 slio.l.. v..,y .ol.l aii(l
" >"- '-'Klit si.l.- ui.i, |i,„|„

-''-■i,Mn.n,..rn:^;;:i:::;;j:;'^.'^^^^^^

""' •■piiiasliiiiiii or

iiiKic'vlciisiv,.

«' « p.m.. u|,..„ op..n,,i„vV ;;''"' '''"'"' ""^'ii.'..Mos..l a„l

: ;;l ""^ -"'-v-n-Nv. I ;;:::;■'■ z ^"""■'"■"' '■'•-•-■> '.:;;!

•""' '^"■•■n.t<.,|. ,„.l l,,,.,uon|,a,.,. J' ""■-""-■.v uas l.,,n.s,.,l

""■ «•" J'-in« n .livHl...! "^"j ^'•:; " '• "" '' -'-'- '.I N in..h..s.

:"""'"" '," "'"-'iNal .■o,„..,„s I,.. ' ; .;;, ""'• " '^""••- <'"ly a s,u,,l|

»•'. pia.vs „... ,„.,,..,n,„i s,,.";:r" ':";''''-■''•-'■'■•' '•".■-..•

I llliili 11...- ..IV . 1 . ' " '" l< MIC liiiu,. .,,,,, I ,

ol til.. M-iit „as 111,.,, ,li. , . " ■" IlinsI (|„. ,. „(,,,.

,. -r. a'liinsi (I

"■" <lis<-<>v<.ic(l. al)oiil Il>

Pl=^>.'s was ,1,„... ,vi.l,o„, ,vs,.,,i„ ."'"'. 7"^""'.'-i^ "iti, s,.n,.s

;" ' '". '^"-. "I,... v..,ni,i„. ,• v;;; : ;;:''^' '""" 'm^ "" ".«• .■-nin.

'"'■•" ■■<-«..s ol P-, it„„i,is. -n,.. „,,;"' "■''■'■", '■''"'".......■.I pain an,]

J..S <-on,li,i„n n,„ p,.,niilti,i..- „ I, '""•,■'" '.."'.•■-al an„s was nia.l,.

»l'.; n«l.t lunjr was al.so .li.srov,.n.,l '-^fLMV,. ha.nn.nha... into

,, . '"•"•• (l\,'<'l)V,.lV)^-\ «;,,,., II I ■' 1.1. Ill nil. .\f|:s|. v;.

>"'•.■'.. HT :u. luUK liavin. Ln ^i^UaZ' "'"' '■ "'" ^"''"*"-l "."
"<• "■••^^ V.., y sick aft,.nvanls ui.l . 7 """' "" "'"' ''"^- '"• .i".

varils. If, was then U>oku^l v' V u i . . , i'V'^"'^ "'■•■•• '"•"- -l'.'.-
;'''.a-.<'.'witl.(ai,itl.n,i.s,.,s,,,-,l, s i,, "''"'"'"'■'. ".'■'■<■ "as ..,.,.„ „7

'"•-'-'ii<... Ti... p,i.s;wal ■ ,' '!:, ';;;; ;'"; ""v;'-^ -.<■ .i.i.i ..u, ;!

, Jl" a.nv,.,l whilst I was .„ ;, i^- .' "" '""'•'•■• T..,n,„.,„ „,,.,,;
''''''''•.v'..Hn«,ak..n,li...,.,,;',;.\'r''''^''- -;'.'.' .." .iiii.. was |„ , '

; '■ '""^ "•■ "'•' '."'Ml.' i d I ;::;;; ""■ "'— -- .'.->-.;

/" ;"""."^' <!'<■ pnit.,,,,.,.,,, I,.,... 1 ,,1 ,"'""■'" """*••' "..' wants.

A'H.ut 3 IV,., ,n,„;n,,:';;...,::r;;,;:'r!,;"^ '"•"'•'

xn.ii Aaue 111,. UK'S,. 111,.

TRAl'MATir RrPTrF?E OF TTIR VISCERA 4)

lonjiitiiditially. ;mi(I son... wvsrls w.T.. l.l..,Mliim |,v..|v. A |.,.|lo,Mt ion il„>

si/c ol aii ..nlinavy iiy.li<..-..|.. tro.-lnir w;.s i„„M.l iii 1 1„. i,iitiin.vs,.Mt..nr

H.nl.T ..I llM- j;ul. ;„ tl... >ain.. I..v..|. This wm. rlos...! I.v ;, .onli.nu.Ms

I...|nl...,t sMlinv ,.t silk (N„. I). Th,. l.„r in 1 1... ....•s..,il',.,v was ,.|„„..l

illl.T li;,.i,tmv ..I \v>s,.|s iili.l III.. al>.l.,iniMal wall .■|..s,.,| inlav.'!-, II..
.l..v..|..|H.,l s.,.,i.. i.r..ii..|,ial i.iH.im...ina. luil ii uia.liiallv smIkI,!..,! (.„
.laiiiiaiy :, a laii;.. .,i.ai.lily ..I .•|,.ai- Ihii.l ..am., awav' Iron. III.. I.iw.r
l.arl ..t III.. w.Miii.l. ..vi<l..nlly i....ii.Mi.al. an. I ....iil i.m..,l i„ ||„w l.,r i

lew .lays. 'I |„. i..in|),.ial iir.- I.,...a ii..nnal a< lli.- Imi-siirns inii.i..v...l

and li<. I.'lt liospital ..ii .[ainiary :.':!. I<i||. I.avini; .|,iii.. i......v..r,..|.

M. In 111.. s....(.n,| licinp tlicn. is ikm.s i.|..|it slnuk. an.l |...iliai.s
flu- i)ati(.nt walks i,, tli.. Iiospital. ..r <r,„.s h..ni<.. .•..iiL'ratiilatiii^'
liiinsi-lt that he ha-; hail a • narrow ..scaju- " ! M.. may havr.
voniift..! soon after the act-i.U.iit. Avhicli ina.l.. Iiim U-v'l faint.
hut then, arc no marks of injury on the ah.loniinal wall. ..r
Ihcy ar(. hut slight. U<- has (•onsi(l(.ral>l<. I,.,.al j.ain. an.l thc.r..
is rigidity of nuisck-. sometimes e..nfine(l to th.. side .,f the
ahdonu-n whieh was struek. Th(.re is t..n.l<.rn..ss ., ])ressur<..
and ])erhai)s lo..alised dnhiess. hut tiie man tVels that h.. will
8oon get over it. and prohahly remains un.ler tr..almehl with
reluetance. or iiegieets to call in medical a.lvi(.e ..n his n.ti.rn
home.

This gr(.u]) f.Mins ahout :!.-, per eent. ..f tiie total nmnh..r of
easi's.

In a ..as,, wlii..]. 1 ...ininnini..al...l t.. ili.. l'at}i,.|.,Ki<.al s,„.i..|v in Iss',
ni wlu..li 111,.!-., ha.l I....M1 ..M..i,siv.. la....|ali..n „\ tli.. small iMl.'.siin,. il„"
imti..nl. a man ..f 2.-,. an .,sil..r. lia.l l,..,.n ki..|<...l l.v a l..,is.. a! .-, ,. „,
th.. .lay I,..!.,,-.. a.inussi„i, i., hospital. II.. s....„„.,l „,ial.l.. t.i ,u.,v,. I„r
hull an h.,iir. I.iil tli,.n w..!it on with his work nnlil t;.;!(i p ,,, |i,. j,.,,!
to.Kl on n.a..hinj; h.nn... I.ut v..niil...l il aln...sl innn...liat..iv, an.l was
n.sll..ss .Inn.iu th.. nijrhl. llowyf. I,,, tvlnn,,.,! I,, work in th.. m.-niinj;
at t. .. ..|....k : was nnal.l.. t.. ivsun... his w.iik afl.r a slij.rht l„..aklasi
IxM.aus.. ol th.. ..n.s,.t .,)• pain an.l voniilin- II,. pass...l into a stat.. o|'
.■Mi-.'m.. ,.,.lla,K,.. an.l .li..,l tw,.nty.s,.v,.n an, I a half hours all..r th..
ki..k. Ili.iv was an ..Nt..nsiv,. rii,,tii,v ol th,. small iiit..Miii,. an.l
mloiiso ])..iii.)nitis.

hi tiie foll.)wing ease we were mu..h hamix.red hylh..
aleoholieeomliti..n(.fth(.].atient. In th.. (irst plae.-. the vomit -
iiig was mistak<.n for the results of think : in tJie se,..,Md plaet..
lie was very intolerant of di.st.jpiiiu- : and in the tliird. his <;<-neral
eondition was very unsatisfactory from chroni.. alcoholism.

On II,.. nijrlit .,f .April 4. IS-IS. a man a.n..d 27. who was ,i.,ssi,„.
Wiiilohall wli..n ui an iuio.\i.al...l ...^1(11.^, was nm ov..r hv a

! i'J^tfKT'M^iJf

M I

! !

TJIK Acr TK AHDO.MKX

tno-wlit'clcd vi

iilliuissjoii.

Ik

Wils t;i

-" Wils lin

ken to

il IH>S|)1|;|,| li.'iU-. Illll

Wils icImsimI

"iJl" I" St. TluMriiis-s :il,„„( tl,r,...-.,,iinl,.,s ot ,,1

...wnpii ,J';:j;:;;',;;:::;,;1''; -;"-;-„.., „„.'i.....i.,:„;;',::

I'-.l- fiiirlv .„. . ,;.;,''■''• "'"■?■ ""•■'■ ""•"• '"'*"<^ '" "lH...|s.

tu" ..i«hf till V • ;,?i r ■ '■' '• "'"' ""^ '•"•" ■■' ^'1' 'i""'>«i'

:i i...".. win.., his ..o,Mi,„o„ ;i.s ,y,rt L . , "V ': ""■ '"'" ^"

)>.'lloinMMl.:,| Whi.'ll ■ll„,.,.nn.,.,, ''■'■''■ "I"l-"l"ll Wils

was ro,,..:u.i:;.::;":^ ;,::;:■;.:-■,;:;'■<■;:;:- h

wnv .s„ili,.i,.„t to ,.|os,. i,. Tl...,-.. w ,1 I ;",'"" '"""'"

sunou.t.li,,. ..oils. Th.. iilHl, , , ";' .. -"""'''":' •" '>"'l''' "" 'J-

;i:.^":cr;:;i:v-;;r;-;:;7'^-''r-^

thm> is M'T' ^'T''; ?'" .^>"'J>'"- -•<• -atl...,. i,..|<.,i..i,.;
tlcri ,,s .t l„sf„ry ot uIkI..,,,,,,;.! i„j„,,, p,ol,i,1,lv of the kin,

:::'"•""";■ ?"" ^ "•• ^■""''♦"'«- '<-' p-- i^^ « /

mn^i ;■ " ''^^'^»-"'— - "<' n^'i'lity of ,>n.s..I,.. ^l il
Huusston sl.o.s ,.0 cJ.a,.,... After a vani.l.lc- ,i,„. ,1,,,,. m av

'""— ^»';'>'- ft "my t.ot In. oasy to si,,y i,t wit., uZ^Z^

tU r ,„ attack ot vomm.tg. i.s ,„ titc- .as. „,„|,t tl... , .ro of tl..
ate Mr. \alsl,a,n. Tlt.s sur.,-,,,.. mI.o .as pa,i,-,.tiv wato , 1
for sym,,to,„s. ,„ a .'its,, of ti.is kitt.l. fo,.,,,] '^'^'^i^^^^L

--" —....I s....,...s. .ny..ta,.otiinpatu.„t,.:o,:;:;:;;

■ J ji» 'j^-*"

'ri!.\r.M.\'i'i(' liiiTrHK of tiii, \is( i;i;.\

t:{

sfiioiis Nym)i1(.ins iiiay lie Midden jiiid niic.\|)c(tc(|. ciiiiscd hv
the jiiviiij; Wily ot ,i portiDii of the ((iiilnscd houcl.

Ill sniiic iiistiiiiccs. especially wliere lliere is ji deliiiite liistory
t>t the kick of a Ikiisc or mule, it will Iw judicious to operate at
once, as recoinniended hy Mr. Ueriiard I'itts. without waiting
tor syinptonis.

Should the escajie of intestinal contents he very restricted,
jiossihiy ill cMnse(|Ueiice of the snialliiess of the perforation, the
syiii]it()nis may he limited to occasional sickness, with un-
«'asiness in t he alxlomeii. gradual distension am' •;eiieral tender-
ness, caused hy a slowly extending iiitlammation of the peri-
toneum, which may hecome localised, and result in the forma-
tion of an altscess. It must he remeinhered that ineteorism
may follow an injury to the abdomen witliout iiny rupture of
the intesM;!' or internal organ.

A rigid condition of the al)doininal muscles is a verv imjxirtant
sign : it jiiactically always means seriou.s underlying damage.
Cases in which it is ])resent may. in rare instances, recover. i)ut
it is a sign which should lie regarch-d as of great value, and in
most as an urgent indication for ojx'ration. .Mr. Croft comjiared
it to the ])rotective contraction of muscles round an inllamed
Jiip-joint. Hartmanii has al.so shown its value.

No deduction rega.ling the value of localised dulness on
percussion can be drawn from i)ul)lislied cases. In the large
majority the condition of the abdomen (»n )K'rcussion is not
mentioned, and a])|)reciation of the slighterdegrees of abdominal
dulness is not universal.

.Mr. Uernai-d I'itts thinks that dulness at the site of contusion
may be due to colla]ise(l intestine, as a result of a tem|)orary
])aralysis following the injury. It has l)een ascribed to escape
of intestinal contents : this may })e so. l)ut it is rare to find much
feculent lluid ])resent when the abdomen is ojiened soon after
an injury, although blood may be found which has come from
a ru](ture of the mesentery or a tear of tli(> omentum. .\n
extensive extTavasation of ))loo(l under the jM-ritoneum of the
anterior abdominal wall will also cause dulness which does not
move Mitli alteration of position, liut this is a verv rare com-
jilication. If tiiere is a history of localised contusion, such as
that ])idduced by a kick, and in addition to dulness un(U'r the
])art struck there is also lluid in one or both Hanks, the meseiiterv

t i!! 1

BUmmmi

44

TlfK ACITK AHDOMKX

: I

IS lorn. an.l. wl.alcvcr )l pjni,,,, ;,s to th,. vtai.. of the j;iif

tlic iiidicalions for ,.|M.)alioii arc cvid.'rit tiist. to j)rc\"ciit

furth.T l,l,.,..lin«, an.i. M.<,M,(lly. to ivpair til., in jnrv. winch niav
i.iivc placed the jiut in daMficr of f;at.j;rene l,v deprivation of it's
blood supply. When the injury has 1,,.,.,, less localisc.l. such as
that resultinji from a fall or from heinu run .,v.r. it is possible
thai then, may 1... a complicati.m in th.. shape of rnptur.. of one
of the soh.l Msc..ra in ad.lition t(. .lama^'.- ,,f th.. |„,w..| an.l its
iu«.s..nt(.ry.

It has been obs..rve.l that lo.-al (.•nd,.rn..ss is usual. I)ul tlwre
may also be a sharj) super(i<.ial t<.n<l..rn..ss ...xten.linK from the
ruj)ture towanis a depeiulcnt jKirt. indicating th." .lir..ctioii
tiil«.n by tjuid of cjn.at irritativ.. prop..rti,.s. in its cours.. to the
flank orthc pelvis.i In on.- pati<.nt with ruptur.. of the splenic
llexure this si<,'n was ]m.s,.nt. an.! was caus...l bv the ..scajH- of
(.tTensiveficcal lluiil from an op..ninjr behin.l t he" b.»wel through
minute ia(...rations in th.- perit.uieum. an.l its spread .lown to
th.- pelvis aloufr tlu- inner side of tlu- .l..s(..-n.lin<; .'olon. and at
the .operation som.. of it was sponjr.-d out of tlu- ]K.|vis V
similar t..n.lerness may be found in ..xampl,.s ..f the rec..nt
rupture of a jejunal, or ..f a stercoral ulc.-r : it is found soiiie-
tim..s at the margin of a sjm-a.ling inflammation start. -.1 l.v a
diseas...! ajipen.ii.v. an.l more g<-n.-rallv .lilfus.-.j. in acute
hii-morrliagic i)aiicreatitis. Kvi-n wh<..i oth,.r svmptonis are
slight, this alone should indicate caution in prognosis.

Th.-re is another sym])t()m which mav ]).)s'^ess more im-
portance than has hitherto been accorded if. an.l that is a
marked rise of temperature within a short tim.- ..f the injurv
It was im-s.-nt in one j)atient beton- th,. bowel gav.. wav (o.i
the secon.l day) : here UK)' was r.-cor.h-d within a few hours .,f
the injury, whilst the usual local signs w.-n- still abs.-nt There
IS i.robably some absor])tion through the lymi)l.ati<.s from the
la.rrated i.arts .,f the gut and ines.-ntcrv. for it is not found in
many of th.- cases in which the opening is ..f large size an.l the
escap.- of tecul.-nt flui.l ,)r.-sumably greater : whilst in th,- ..ase
to which I have allud,-.l f h,- rupture was a secondary one.

On (.,f.,l„.,. sih. 1!M,4. a l,..y a,,v.l I-, „.s a,l„.it...,l at 7 ,..„.. will, a
h..t..ry ... „.,ury t„ th.- al..!.,,....,.. .U ;i ,..„>. he uas walk,,,. .1..,, ' 1
row ..1 mm posts, au.l wh<-u st.-i,,,!,,. in.n. „nv post to aiioll,,-.- Jus l.^ot

' See p. 'Aj.

'M.

»"il«i "W'T.'NIMUll

THM'.MATIC l^lPTrHK OK I'lIK VIS( KItA ».".

HiipiK'il iiiid Iir Icll. slrikiiin his ali(liiiiicii on llu- pu^l in fioiil. lie
luiiitnl. Wiis liikcli Iiniiii'. ulicii- hi' Wiis >i('k M-vclikl liriics, aliil roiii-
]tliiirn'(l ol yrciil IciuliTiic^s in tin- alxiomi'ii. lie cdhIiI iiol pass his
Wilier. WlifiL linmu'hl 1<> lli<' li<is|(il;il lir Was still siitlVriiii; lioiii shiM'k.
ami <'iiiii|iliiiiir(l III pain in thi' lower pari ul the n' imuen. This on
evaininaluiii was lomul In iiiiive lairly well, was mil iiiatkeilly riuitl.
though siiiiie ri^'iilily was present alioiil the lower jiarl of tin- letl
leetiis. 'I liere was ti'nilerness aroiinil and lielow tlie ilinliiliens. Iml this
uppeari'il In lie rallier siiperlieial. There was no area ot (liilne-s in
front anil no sliittiny; iluiness in llie Hanks. Tlie liver dnlne^s eMeiiiled
from the sixth to the ninlli rili. .V eiin>ideral>le i|iiantiiy of elear
iiriiH- was drawn olT. I'uUe |(m», of small volume ; temperaliire '.I'.t .

It was .■•lated thai for two or three days liefore the aeiideiit tlie Imy
had had a eou;;li and >wealin;i al ni^dit, and had talked of ^'oiii^' to the
hospital for medieine.

Oiliiliir '.). lie was sii'k at !t.:!o last evetiiiiir. Init sinee I lien ha-; not
vomited. iMiriiii;- the niujil the teinperatnte went up to lO.'J . and the
jinlse rose lo IlMi. '|]ii> moininj;- 1 he teiiiperat lire wa< lol . puUe I In.
and the patient seemed very comfoilalile. Irini^ normal. There wa-iio
diminution of liver dnlne^s. and no iiiereasc of vif,'idily of the alidonieii.
lie said that he hail no pain unless the ahdomeii was touehed. .\t .'! |<.m.
lie had ipiite recovered from tire shock , and pveseiited the iisjiect of one
siilleriiiH from reaction. He was Hushed, with red lips, hrii^lit eyes.
and dilated pupils ; the pulse wa-s Hit, utid he was dozinj; comfortalily,
lyini; on his back. The thiyhs were' not Hexed on the alidomen, tint,
were placed strai^'ht. His temperature, which had lieeii lit:! duriiii;
the niuht. had fallen to KK) . The pulse was not wiry, he wa- iml rest-
less, and tlie vomitinj: had ceased. On examination of the alidomen
there was no ahrasioii or mark to he .seen. It was normally di>tendeil
without any visililt; jieristalsis. He could draw a deeji lireath without
jiain. On palpation tlieie was no rij;idity of the muscles, lint he cnni-
])lained of a yeneial tenderness, init excessive. 'I'lie ])ei'cus>iiin note
was normal throufihout. the liver diilness lieiiiu' satisfactory: it was
thought thai the note was less clear in the Hanks, Iml this was |>nt do\Mi
to th> greater thicknes., of the muscli! there, for it did not alter witli
jiosition. The (ijiinion jiiven then was that we had no eviihiice of
compU'te rupture of tlie ^ut. lint that it was ipiite jiossilile it was severely
<'()iitused, and that it mi^ht ejve. when immediate operation would lie
re(|uired. This oiiinion was founded on the account of the case u]i to
;} p.m.. not on the local condition. .Mioiif ."i p.m. lie ajiaiii complained
of .sharp pain in the ahdnnicn. and the pulse rate increased to lliti.
.\t 7 li.m. the ahdnmeii was rather more riuid. and there was some,
diminution of liver dulness. \\ it.IiK p.m. he viimiled a consideiahle
(luantity of j^rcenish lluid. and the ahdomen was slii;hlly more ri^'id,
especially alioul tlie up[)er liarl of the left rectus. The pulse wa> 12I>;
the liver dulness was less <'vident, liut there was no dulness in the Hanks.

Median section was iierformed at 12 midnii,'lit liy the resident assistant-
.surjreon. wlio found evidence of recent pi'ritonitis. with some free lluid
in the pelvis, which had run down the desceiidini; colon. In several

:l

4 a

'''"''' •^•'ITK AJJDo.MKx

y-^^^^^^^^^^^^^^ '■'■>-

r-vi;j;!:r;;;;;;;:r,;;;;;';;;;;;;-;;^

;;"-'^tion tor ,i,,t Jesi.,, ' ''•""'^' ^'"- -""- "» '- >

''^' -''^..inal ,..,.„,. and lis ,,^;""^"-'- '*>^ -ay tl.n.„,

;- /•<:-' 'uptun.;, iH.i.rtt*' ;;;;;"' ""•" "■'" '-•«•■ ''>-

.^^''';'\'^ *-'t by fi... fingers i,;,,;"^.""''"'"- '''''<' -aH.ling
'» »''Hocalisati.,n of iU^ru^ur^Zr^'"''- ''''''' '"">• ^-^
'•P-HHl Tiu. only ..ase.s fZ;^2 I '"■'•'^""-"" '-^ ''.■<..
[^>""cl ui the vomit m,.,,. tl.o .^'"^ '" ^^■'"■*'' '''"•"I was

^f'^. '"'^v,.!. ^^ 'I- t'HTc" any blood passed by

'"^oiiiotlnnij iiiiisf l„. ..; I ,

;^-a.in>,..b:;::l.:-;,^--';n.a,n.ntineas..s..

^^- ".ust bo gui.le,! bv gen ; . ; , ' "'" '"' '^^''' ''"^vn.

"'-i. better ,,.,sino.. tinu ^^J^^^"'^ -"' -.' in a ve,.-

-;»^' - an ai.l agau.st sh, !"" "^^ ,, ;r;i'"7 ^•^♦''<' 'Cognised
subcutaneous tissue. ,,a.sse,i in. . '' '"•''••■'^'•' '"*« tlie

'•-turn eontinuouslv. We /V'""' '"■ ""--<' <" -Uer tl.^
'''J"nosofthes,.li,i;i,J, ,.," '^^ "" ^*"«<-^- '.onev,.,.. j.^

^'■.itl.atlne„u,rrl.ageistl,eehi,.f,lange

! I

TI{\C.M\T|r ini'Ti |?|.:

«"■' TMK VIS( Ki'A

to lite. I

li'licr

ixniiil III) 1

anvs) It is canicil .mh (|

ii"iv <l<lii\ IhIuic (I

It has I

»<'<'ii rcc((iiiiii(ii(|(.,| I

"III is i'llx.llilclv

i<'<|iiitc(l.

"' "|itTiiti()ii ti<

I-* ii«i.lity n» tlic hIkI

••iiiiiial wall

•\ >"iii'-siir^',.„iisf|,af ulicM II

KTC

"""'••'"♦'"• part. s,,f|,at if f|

"■I'lM applications sli.,iil,| |,

tlxl

'""'iial wal! alnii,. it

!<• MjrKllty is (111,, f

I'd' and til

liarill

<• patient lie

V iiccc

•"".v liavc a Ix.tt.T ,1
ivcd a possil.lv „s,.|,.

" "ijury of the

»i>iitinii((l for

aiy to say that this t

ly^ival Icniith off

laiicc of passing

I'piiation. It

■•'■■'tMicnt sln.iild not l„.

••triipfiiivofth,- intestine. I

iiK'. if then

will
I

"II SIX hi Mils ii

I inaiiv of th

•ecaiise peritonitis is |<|

IS any possihility

lo

in

iiy refer a;;ain to M

• ■se ease:

wii to hej^ia

IK

>t "Illy that th

•' niortalitv

fssis. IJerrv and (

FKTtoriiH'd. |„it that the I,,

is le:

••iisep|,i. „|„, ^1

done JK'twcei
is prat'tieallv th

seven and twelve I

wlien early ,,p,.r
» lesiilis are ohtained \\\

lour..

low

ition is

K'li it i.s

and Is

_-^.iiiieeonelusionastliat to whiel

dter the accident. Tl

lis

IMTitonit

explained hy the fact that tl

ts is

By

•'till localised, if it h

>hoc|.

1 Sie^rcl ,.;,„„

< IS passiiicr ,,(J\

opefatioii ill c

stood abdoniinal sect
repair by suturin<f.

ise

IS eoni!iienci.d.

and

•>t iiiptiired intest

ion. a search for th

iiK- is here imder-

Tli

easy aceess to the intest
placed at the level of t|

e incision shoul,| he a I

"Jiired jruf. iiini j,.

"e. and it

oiif,' one to

■s central

give

necc

ssary to excise tl

iinihiliciis

li

pertonn an anast

sutun

tl

(h

oin

ic contused and lacerated

osis. hut in tl

l>plied as already advised

K' niajoritv a d,

on of an artificial

Wll

■<iifiHc

point should ()(

^onie it jiiay b(.

"I't, and

f

precated. In about lo

'""'^ ill the small inte.sti

TIef

o
orniH

esion ; forgetfuin

Tl
be

<'ss of this fact

per cent, there i..

lie is to I

>e much

le surgeon had better satisfv I
gins to apply suture:

may lead t

iini.sdf on thi

more than one
o serious trouble.

point before he

Jt appears to me that

cases of iccovery in this brand
advance ill the after-treat

some of the

1 of

guide

us 111

nient. founded on tl

more recently f)ublislied
Gingery have shown an

}>laced in the '• Fowl

perforative peritonitis. Tl

tluid administered
i^'tlington. W. SI

er position. ■■ dr;
continuously by the rect

K' priiiciples which
patient has 1

lec

U'US. whilst Dr. Kadcl

n. and \V. (;. Xa.sl

)een
ine
urn. Afessrs. (J. H.

linage emj)l„ycd. and .sal

i(fe

introduct

Set' [1. III.

1 recorded sue

;al

cesses ill

ine into the ea-

cum

hJ^ y^'

4m

I'HK \( riK .\i{i)<>.\ii:.\

atf.T ;i|.|....Hl„..Ktn.ny at ll.r nn,. ..I („,, >.m!I„ms i„ iwmtv lour
l...m>. TI.,M.ir..,tottl,isisins|n„,iv,..as,h..|Mli,.,.ln..u;..ml
|.<is|.i.v.|. ,,ass,..l urine fiv.ly. ..ii.l at lli,. ,.,..1 ot ll„. ij,,,,. |,;m|

NUMH- .M.nntll.rrMT. ,.,ssi„« ,,,,,., ,,i,,, , „„„|,,,,,,,, ,,„„„(, ^ .,,

salit... Ilui.l. .\|n,v,.v,.r. tli.Tr was llui.l cmtimiuuslv ^^r\Un.
|.|. I in.n^rl, K,.i,|,s tul..-. M, tl.at tl„. ,,a.l ..vrr tl„. ,„i„. |,,„| ,.,
he cliaiiiinl fvciy halt hour."

A lahl.MM|.. .-,J>h..\vs Ihcn.Milt a. iv^'ar.N a.lual nT,,v,.ri..s
hut (h...s nut show how many wn^ i.h.v.l h\ op.raMon li,
•Mr. (Volt s lir.t .as,, th,. pati,.,,! ,|i,..l a month late, all.r
ivs,..Hon ot the artificial anus whi.i, ha.l Urru torm.Ml in tin-
hrNt n.stan.c. Another |,ali..nt. also i . ,h,. .,.,1,.^ fn.m St
llioniass. hu'd Inra m.mth. an.l still another some mv ,lavs
.iym« ultimately from peritonitis ,lue to th.. j;ivim' «av ..i a
stitch.

!:§

Hri'Tiui; Of DroDKM'M.

Huptur.. of th.. .luo«l..num is one of th.. more rare ivsuits of
injury to the ah.h.nu.n. The hist..rv is nearlv alwavs that ..f
••run ov..r in tl... str....t. " caujiht i...|ween a moving aiul a
statiomiry ..l,j,...t as in a l.utfer a..ci.l..nt. or struck l.v an
opponents knee .lurinj; a toothall match, an.l it is evident
that the .lamag.. was intli..te(l ahove th.. umhilicus. Occasion-
ally the p..ritoneum is torn an.l int..stinal ontents «.scape into
t lie jK-ritoneal cavity : more fre.,uent ly the tear is in the pos Un-
r..tro-]...riton..al part of tl... bowel, an.l extravasation lake a.'o
m and arouiul th.. ru|)lun. t.) a ra|)i.lly in.-reasinjf e.ste As

this (..xlravasation contains a ..(.rlain amount of pan^'reatie
secr..fi..n. there is a swift change in the state .)f the cellular
tissue ot th.. ].art. It may i.e suHici,.nt t.. i.ro.im-e a fi.xe.l
dulness continuous with that of the liver if the patient survives
tor a .lay or two.

Th.. signs of ■peritonism ■■ are .severe, th.. shock lu.ii,.'
especially great, so much so that occasionallv it has heeu
necessary to ahan-lon an opeiati.>n for th.- reliet'of this injurv
he..au.s.. the state the ].atient has ma.U' it ..vi.l..nt that any

cont inuatK.ii ..f t he e.xplorat ion would prove fatal l),.fore he could
leav». th.. operating tiieatr... In addition, there mav he hoard-
like rigidity of the ujiju.r aixlomen with great teiideriu.ss on
pivssure, emi.hyseina of the abilominal wall. ijl.).)d in the

^li«t=

Tl{.\r.\f \T|( Hri'TrMK of Tin: viscku \ id

Vninif . aii.l nil ..priiilij; flu- <llMl<.llirli I.Muii.r.l r. ria inn.i. ,,| |||,.
IxTitoii.iiiM, ami M.inctirii.^s tat iirrrnsi^ uf ihr Kin.l .,-,n in
acute lia'iiiorrliattic paiicicatif is.

Sornr nf ilu-sc |iati.-iifs .lie (rum ,1,,. ,h,„.K, ,,il,..r. an.l (1...
Minn- i,i,„„.,„„s. as a ivsult of iiillaiiinial i,,ii n| tl,,. nli,,.
JMTK.. Ileal <..|lnlar liss,,.. ; tlientn,,. it is w.-ll tu arianu,. lur
<lraiiia>;<. ..| tins iv«i.,ii. The ivr..n|e,| ea>es ut leenvei afl.r
o|MTafioii are very U■^v iii.lee.l. Tiinse of M,.,,,.. «;,„|wm an.l
M..yMiliaii Nv.-re at .,r near the .lii,»leii,, iejimal jiii,eii,,n It it
IS ,...ssll.le t.. tin.l th.- ..(...niliK in the ,u.,itnne,.ii,. the l-uuel
mi.lernealh must he examined aii.l treat. d l,v >iituiv it this
"IH'Miii^' is small an.l a.-e.-ssihl... Mr. [,avvt..r.'l Kna-us. u|„,
• •IK'neil a .liseussi.a, on this siihjeet at th.' |{.,\al Sn.i,.tv nf
MciieiiH-.' .h-se,il,es a .as,, in whieli he sutuiv.l th.. ..p.n'in.r
whiehwas I in.'h fr.mith.. ..yhiius. with a ,.„ntin.i.„is Mitiin-
through the mucous and muscular cats, an.l appii..,| inl,.r-
nipted Lemhert sutures outside that. At (he necn.psv t w.nt v-
lour h.uirs later these lia.l hel.l. Th.. .Iraina-.. ^as'pn.vi.l.'.l
term this case l,y three tul.es. .,ne in th.. rijrht Hank t.. tl,..
kidney p.uich. one int.. the jM-lvis. whilst tli,- ivtr.., ,.riton..al
.s|.iice was drained thi(>uj,'h the al..h.iiiiiial incisi.ai. hi thi^
tile second of two eases n-lat...! I.y .Mr. KnaKus. th.. patient
was a man of I'O. un.l opc.ration was perf.)riii..d m..re than
twenty four hours after th,. iiip,, i.a.l I.,.,.n inlli.|,.,|.

If there is ,.onipl,.t,. riiptur,.' ah..v.. the entran..- .,f th,-
l)ileduct int.. the sec.,iid part ..f th(. (Iu...l,.num. th,. I.est m,.tho.l
of treatment is t.. close both ,.n.ls an.l p,.rform a p.stro,.ntero.
.stomy after the meth,.d .,f May,., or l.v lh,. ..r.liiiarv ant,.rior
ni .tho,! which tak.'s less time for its p.-rtorinan,.,.. rhoh.cvst-
cnter,.stomy must also 1„. p,.rfornie,l wli,.ii th,- ..ompl.tc
lesu.n is l),.|,)w tli<. l)il,. paj.illa.

When a eomplet," ruptuiv has tak,.n pla,,. I.,.|,,w th,. ,lu,.,h.iio-
.jcjunal juncti..n. a m...lilicati,.ii of th,. ..p,.ralioii of .rasim.
jejum.st,.my -en V.- of Hou.x mav !„. possihl,. hut the
l.n.ximal liml. may he v.-ry short an,l iv.piire soni,. skill to
adapt it t,) the eiferent loop.

Those are suggtsti. ns of po.ssihilities. hut in a.tua! pra.tico
there is rarely a chan.-e of doing m(.re than p;..ck an.l .Irain. on
acount of the ,..\c(.ssive coliaj.se.

A.A.

Sif \"iii. \ .. .\ci. !l, II. i>4;j, I

laii.s.iitmn^.

I

r>o

V'lK \(l iK MUKiMKN

I{| I'll i:i; III I mi: I.ncci: Itnw ii..

I?ll|lllirf ol till 1,1 liuwrl li\ l.ilir, linlii \M||iill. ll.ls lii'cll

tM < ilsi.i||.tll\ -Mil I) \||i||(«-' lijs iliauil ;ilti'llthill \i< tilt'

''•^''"'l "I ■• |iirs^.il 11 fiiusin^ tills aciiilciii. Mill piiMi-^litil

il IIIUSI ill^lnilllV II wllit'il III' ll.lll |l. CM Kc ;| |llllllnl| III

tin- >.ij.'IIHM(l . 'Ill ,..,.,., till illl.l-ll.||ll«-,K, II*' I iiIIitIi c| lilli'i'll

otiirr cjivi-. ||. \.iiiii ,1 >uiiiii-.. 'I'lir .III' linsr wIikIi ji'inls

111 Ihr i'.i||i|in's ,1 II |,l\ I lii.l 111' ii|i|i|iril liirciliv 11. the

itillls, lull |iHm|i,c, , !,.,'| lliii'll^ll l!if I'lnlliilii;. nil|it||M'

is ll-lliiliy III till i.h, ml III; \ III' Mll|lli|i|i'. All Ihi- I'ilM'N

nut Miltiiiittiil I . iHiii , . flirt' • n ul Iiit cmm's. ii|ii'i'iitiiiii

tlUI^I I.I' CMlly I' I,.. . illllssl|M'(.|.t|.i|| \\;|s ll'citl'.l

In iiU'.iiiN III ,i> ■ ,.'■ I ( l.iiwi'l, iii|iiiii)' ..I' til)' fiiil

was II, I iiiikii,,ui II 1 ,,, , I ,11 jijsii l,\ .III .itti'iii|it III

IhlltKllIll' III," M;..', ,|,|i,v , ,, ,,;|ss ;| l.llliC llOlluil' tllliumll

il hiuli ll.lll lli:ili' 'l.,iit .,1 . uliiii III,. |,:itii'iil I-, iiliili'i'

jiiKothi'-i.i. hot riiiiii jii'i l,.r.,i :,,ii liy till' liiiiij/ii'. Iiiit III, III

imsllillU lllf IM hl-l;,- sIlH'tlll, lipWiirils. Ill I'iisi'S ulll'I'c

I'lHhi.it;! Iia\i hii'ii |,ii,i'il mil) III,' |ii'i'iti>iii';il I'.ivitv it is
'siialiy ililliciill tn s;i\ « hrt lirr tl.c iliiiii.ip' Ii;is lici'ii cjnix'ii liy

till' lln/./lr 111' fliiin Inn Inliiliji' (lijivciy nf tlir IJniil jntn .iji
nhstrilctrd ITrtllMl.

I!l I'll 1,1. nl im. I»l>i I ShlMi r,.|iiS. Willi 1. M V:i! MlilSS III IIIK
lUii.'i^lM. ri,i;i l.iM.i M. A XMiliiiiii :mi'il :i:f «:i^ Im,,iii;IiI :iI IlM :■ iim.

oil .liilv I », l!MI7. Iiiiviliu liii II Mill i.vi'i liv ;i hiiiHi'ii oMiliiliiis. 111.' \vl I

ol wliii'h )ii»s>|.il i.vci' III)' iiliiliiiiii'ii iiliiiiit till' Ji'MJ III till' jiiwir nlm.
W'Ikii ;ii1 III III I'll sill' \>;h |i;i1i' nml rii||;i|i>i'i| u iili a lii'Mi' piiUi' Il'ii. anil
a li'iii|H'ia' nil' nl HT .

Piniiii; III,' iiiulii -111' \\a^ >i. I, ,in>i'. -iiltinil imii'li |iaiii. ami was
I'Vlili'lill.V wiii'si' III I hi' iiKiiiiiHi;. I >,'iu lii'i al hi a in. Mni'li nl ih,.
slini'k liail |iasst'il nl). anil li,' «a^ Mim -min'wlial |nn|i|ii'il n|> m |>,.||
with i|iiii'ki'n.il ii'-inialinn ami piiU, Slii' « a- I'lnniilaimiii; nl jiaiii in
lllr li'fl -iiln nf i ln' alnliiini'ii ,.m r llii' Inwii rilis. ami llii' aliilnini'ii ua-*
mil linivmi.' wi'll Willi i','.,|nraliiiii. I'ln'r,' u as lijiiilil y ,'s|ii'i'iall,v inail»i'il

on till' li'li sill,'. Willi cxi'i'-MV,' li'iiil<'i'ii,'s> ,'\l,'iiiliiitr in a lini' ti ihi'

>ili' lit llii' iniiirv i.-wanl-- ijii' iirlvi- sh,. h.iil |i.ism'iI iirjiii' nf iiininal
aii|ii'arain'i'. Inil tin' ImwcU hail mil atli'il. Tliii,' was no I'viih'iil
liniisiiiy; III t hi' sivin.

Ti'ii htiin-. alli'i' I he injiiiy ,i|ii'ralinii wa- ranii'il mil llirniii;li llii-
left ncliis >lii'aili with iliN|ihii','iiii'iil nl I lir iniisi'li' inwanls. .M iji,.
Iiis.1 : ^pii'tinii lliiii' ua- lillli' vi-ihli' iii'Voiiil a ^iialrlnil a|i|ii'ar,iiir,' nf

' •■ >i!iL' :.v. <i_vii;ii',.;(.cv, .111,1 (lli>t, Iri,'-." .laiiiiMiv Wl \ . S. \ .. /.,i nr,'t. \i,\ I
ll'll. p. .■.:'i,

■■v'm^^.jimm.

TKAI MATI. Kli'll !{(• Ml' T||,: V|s( |.;i: \ .-.,

;ii"TT"r"'."" ". ■ "'• "™ ^ ' "'

"•'• ;-"•'•''••■•'"... .,.,,., ,K ,..„ ,, ,„.,

' '"'■'^ ' ' "'"' '•■'••►I -..1..,,.. ,,, ,..„ ,., ,i„. . I...,,, ,,,„„, '

;•■;'■;■ '^•■'••"•'••".n.i. „i„i-, ,i,.., m.....,,.,,„",i..,h

""'""7*^'' -'...ii-.M-nMi,..,.,. ,„„„.. ,. , „ ;''

"■'"■"",""■"7 '■;•'";"' ""■-;'^-' -i- i .....,,':,

Ciivilv )'\t.'ti.|r,| ii|(w,nils into III.

lM|i.|i.Mli,fM;il 11, -II.' Im'IiiimI Id.

-■<llul;u l„sMr, Tl,.- ,..|,..s ..I ,1,.. ,,.,..„,. «..,... I.„ ''

IIll.TIU|>l,l| ,l|k ,11(11,,.,. ,|„, ,„,„„|,|^ I

■'ii:lii loij.ili.'i null

.... ,.|....„ , , - '■" '•*■'"- II'*' ""I III-' |..ril.iri.„,.'
,;*;""-'■'• • Z" "" ""'-V- I.I I ,,;.|.i,..| ,1,1.1 M ,.,

K.M^ ... sh,„ ..,r ,1,.. „,.,,.. ,,,, ,„,,„.,, ,,„, ,,,;^^_,, "I- •-!

""■ •' • "l-ii'iU'.." II... I.rti, .luv .1,..,,. „a,.:, ,1,. ,„.„,

IMTHlUI... an.l UH ll„s .|„| „..( s,.l,M.|.. -. .... .,, „„,,„|, , ,

.l.i.v -'...•..•. ..I tl,.. |,..|,v.val,.„. „.,•„„. „,.. ,,,,...,.,1 ,.„„..,,..,„. "

r '"' '"'- "";;"•<'•" •■'•""• ''"-V t,., ,,.,.,1, i,v.. , K,. ,1,.. ..„;. ;\, ,;

..•-on..... HM.ai..,- In.n. .lav ... .l.,v, .,„, , „.. ^v,.,.,..l ,„.| ,.. , ,

I..-I...V .N.].!..,,,!,,.,- 7. n||..|, si,.. I..t. ,|„. ||,„,,„;,|. ' '

''.'''•' """■'••'li<.V'ilt.'.Ml,„« n.ptur.. .,1 ,|,.. ,„(,..,„„• ul,-n ,|,..
I»al..'nts,,n. ,.I.M....l un.l.Tth.. I,...,, ..,.„.|mu„ , ,-; -.|,.,u„ „. ,„.
fal.l,. ,M. ,.. .-,L'. TI...M. an. ,,|| |,..,,,„,,i ,,,„., ,„,„,^.

S.-V.... o,H.ra.,nnsum, t«..,.,y...n.. n.,.,.v..n... 1., ,|,„ ,',,.„
un. ■n..„,l,..| ,.,|| tl,, ,,,.., .„,,„„„,,| ,„ „|,„,,^ ^^,^^^,^^^

s..r.T,.stul or .ml, 1,„| , ,,„,■,■ ,.Mi„.;,„. is „l„.,,„...| j, ,„.,,. ,,„.
ciisrs t.>r tlic last fen y<.iirs ,irc taken.

I have „..( ,„a,l,. a s..,,ara.,. |,..a,|i„j, „( /{„,,»„, of //,,
Mrsrnl.nr l.e^ans,. i, is Usnally a ..o.npli.an,,,. .,t ,|„. ,„„„.
sever,. l..s„.M, rnptun. nf ||,e iiifstine. Tl,.. sVM,,,tn,n, a. ,,' ■•

snmhiv. an.l altlH,„«h a su..;, n.av l.e e.'.rtain I),,.,.. ,s ■',

lueerati.,,, ni the ,MeM.„t,..y. I„. .annnt |„. ,...,.,a,„ ,|„.,.,. ,. „;,

;"•'■ •'■"'■^"'« '••^i"" "• "h- .Mt,.s.i,„.. TI...V are -eri.a.s

l.eea...s,- .,» the danp.r of in.erteren,.e with tl,.'. I,|,.,„| .unnK-
"f the mte.stine. They ...ay als., he th,- ..a...,. „i ..vte,.-,v'..
h.x>inorrhage.ntothe,.erit.me.n„. Should the se,..rHtion f,oM.

i; L'

;i

r>2

THK .\( TTH AHDOMKN

tlicbowd he oxtfiisivc or tluTc is accompiiiiyiii",' nipf urc of
tlic intcstiiio. the })art iiiiisl hv excised and the cmls uiiilcd
with sutures.

Tiihic Shoiri,,,, /,',.y,(.'/x <,/ l>i„i,ilio,i for T,H,i,n,ilir l!i,,,hnY of

till' lllllsll)n\

SI. Tli.iiiiiis's lli.^i.ilal, ISs

-1:1 10.

I'ril V :iii(l ( liiiM|.|ii

( l.ollllllll 1111(1 niluT

lldspilal^. IH'.t:*— l!Hi7

ilH'lll^ivi').

CiirLvl.

l>io.l.

I 111-.. I.

Hied.

Sinall iiitcstiiu' —

No (ipcialioii
<»l)i'l;iti(>ii
Laijif iiitcst iiK' -

—
5

0
20

N

37
49

No operation
Operation

ij

1
1

3

5

6

10

28

11

1

97

St. Tlionias's IIosi»ifal
Other liofipitals .

•

;!! (iiieratioiiK, It.
«« ., 1 1

rccov^'rios.

Rtptirk of tiik Paxcrk.vs.

The pancreas is another organ which oecu})ies a ])roteete(l
position in tlie U))per alxloinen. so it is very rarely injured hv
anytiiing slinrt of a stab or gunshot wound ; still there are a
few cases on record wliere such has occurred, and the possibility
of it must be recognised in cases of contusion in the epigastric
region.

A laceration of this organ gives ris(> to no special symptoms
beyond tliose of siiock and effusion of blood into the jxTitoneal
cavity. When peritonitis supervenes it is apt to bo ascribed
to other causes.

Should exploration be decided upon in consequeiue of the
urgency of tlu- sym])tonis. Avhicb are n-ferred to tlio region of
the stomach, a median incision should l)e vised, and after
examination of the stomach, liver, and spleen, the gastro-
hepatic omentum should be torn through and the lesner sac of

THAIMATIC HriTlHH OF THK VISCKHA

")3

the iH'ritoiuMini fXiiinincd. H.,m)(1 iiiny lie seen (•(.miii<i tiirougli

a tear of this (.iiu-iituin. or it may lu- seen Wdow the <,'rcat.T

ciirvalurc of tlic stoiiiacli. If tlu'ic is fxtiavasatcd l)loo(l in

this sac. the wound should be packed off and the space cleansed

witii st.Tilise.l saline. Ha'Mioirliajr.- from a laceration should

then he arrested l>y the applicatioji of lij;atures of ratgut to

the hieedino; points. Should this method fail to arrest the

bleeding, dvrp sutures to l)ring the parts together should be

tried, care being taken to a\oi(l the ducts if they have been

eut. If the laceration is in the tail of the |)ancreiis. it will be

well t<- cut this off beyond a ligature, at the surgeon's discretion.

Should it be possible to close the rent, additional sutures of

catgut should be also employed to draw together the peritoneum

covering the gland .so that the damaged organ may l)e quite

sliut off" from the ju'ritoneum.

The ])eiitoneum must be thoroughly cleansed.
In every case provision siiould be made for drainage; the
best plan is to close the ojK'ning in the gastrohepatic omentum
and make one ir, !ie gastrocolic omentum, through which a
strip of gauze the reciuired size can be ])assed. In in,,iv than
one recorded case a i»lugging f the wound combined with
drainage has sufficed.

A complete rupture of the pancreas was sue . ssfullv treated
by Professor (Jrave.'

'J lie patient, a man of 24. Iiatl been cnisLcil betvccu the buffers of a
train.

There was .some liftle puia alter tJio accident, no voniilin^' or iiansea
no shock, whilst the temperature and ])nl.se were normal. 'Ihe abd..men
wa-s tense, jiiid there was some tenderness in the epifjastriiiin. Three
hours later %()niitinfr of cottee-Kroinid.s material, later of some blood,
set in, with Revere pain.

A comiilete tear ot the pancreas was found, the edf;es of which were
about an mch apart, and sli,(ri)ly cut as if with a kmle.

The torn edges of the orjran were brought togc-ther with exact apposi-
tion. and with three posterior and three anterior tine silk sutures through
• apsule and parenchyma tiie <lefect was repuiivd and the hiemorrhaKo
stopped, (iauze packing wa.s put in and became saturated wit'li
socretK.n in two days. Tliis packing was removetl after eight davs and
a new loose ono inserted. In two weeks a drain was inserted.' The
listula closed in six weeks.

Of twenty-four .subcutaneous injuries, thirteen died without

' "Biitrage sur Khii. Chir.," 1905.

WMI

•>t

TMK ACITK ABDOMEN

opfiatioii : oicvcii w.-iv operated on and seven recovered-
thiH o,,eration merely consisted in exposure of the wound ami
draniajie. any l.lood whieh had been efVused Ijeinir cleared
away.

Dr. Han.lail lias obtained success after suture of a laceration
of some 1' niches in lenf,'th. Me employed drainage.

HriTIHK OK TIIK LiVKU.

Rupture of the liver is an extremely fatal accident, and tJie
symptoms which ensue are usually marked and serious. Shock
IS present, frecpiently ])assiiij.' into collap.se and ch-ath. Short
of this there are vomiting, rapid pulse and respiration, pallor,
I'tc. Jn this accident rigidity of the al)dominal wall is very
(■vident. so that it may ajipc-ar l)()ar(l-like. Tenderness l)ecomes
localised to the hej>atic region, and there is shifting dulness in
the flanks with the ordinary symptoms of loss of blood, accord-
ing to tile amount of it Mhicli is effused— the man becoming
restless with a ra])id weak jmlse. sighing respiration, and what
IS called " air hunger.- Jaundice may be a late svmptom. and
IS therefore of no use in the earh/ diagnosis, which is so very
inijiortant.

There is. as might be exi)ected. much variation in the size of
the rupture, wliicli is usually on the convex surface of the right
lobe : the combined statistics of Mayer and Ogston give three
right lobe to one l<-ft lobe as the proportions.

Shock in this injury may not l)e evident when the i)atient
first comes under ob.servation.

F.vr.u. Cask in win, m .s„,„ k w.xs Dki.avki..— Wlion leaving the
Ifo.val tice Hospital .some jtuis a^-o. 1 saw a woman of r.!( l.n.uulit in,
wlio liad IxHn run over in tlio stivei a few miimtos earlier.

Mie was exeit..<l. and vesente<l examination. 'Ihere was no mark on
tlu- a , dome.,, no .Inlness in tl.e (lank., or rijri.lity of the muscles. It
was .liilicult lor us |„ in.luee hw to remain in the lios|)ital. vet three
hours later the al.domen was lull ol blood, and ,.he did not survive
lor many hours tlie oj.e.atiou to ariest th.' l)leedhii;. Th<> liver was
extensively torn jmsteriorly and the kidn..y showed a leeent laceration ;
tlieie were other injuries also present.

I niu>t repeat that all cases of abdominal injurv should be
cur. fully examined during their stay in the hospital, for
secondary symptoms give very few signs which enable them
to be detected.

^m^^^M

TKArMATlC RTPTrHH OV TUE VISCKIJA .-)5

Fatal Cask in wiiirii nii; Svmi'Thms wkki: Si.Kiur. In l".)ll u
mail wild liiul liccii iiijmcd in a motor car accidi'iii was in the iios|(ii;il
for about ten (hiys ainl then went to ji, coiiviilcsi'cul lioiric .•tiniiirciitiy
well. Soon alter his arrival tht'rc lin was iran>linrcil to a iio-pital,
whoro it was notoil liiat in addition to jaundice tlicrc was a consid-'iaMti
cHusion in the i)critoncuin. A lar;;c (piantity ol' tliis was wiiliilrawn
l)y iispiratioii, Iml tlio piiticnt died from j»critonitis. It was foiiiid
that there had been a rupture of the hver.

Hkcovkkv ai ri:i{ (Iai zr. I'a. kfm;. in .Inly. l'.)V2. a Ix.y wa-*
admitted wlio liad hcen iini over and received Irai-tures of i he riuht
rihs over tlic hepatic, reu'ion. i'or two days t liere were no symptoms of
importance, lie vomited on the third day. the ahdomen became some-
what distended and lender, whilst the temperature rose ami the pulr-e
increased in frequency. No deiinite diilriess could he found on
iercu>sion. hut inci.-.ion on the riulit side jrave e.vii to atxiut a jiint of
ilui<l blood which was liecomini; septic, and a rupture of thi' back of
theritcht lobe was found from which blood was llowin;.'. lie recovered
after this jdace had been pluu:j,'ed foi' thirty-six hours.

Tln' ii'conls of cast's wliicli arc piil)lislicfl j,'iv<" no reason tor
tJiiiikiiii.; tliiit tlicrc is any special disease of the liver that
predisposes to rupture, alttiougli it is stated liy a Hussian
veterinary surgeon. Dr. (Jryincr. that rupture of a lardaccous
liver is a comparatively frc(|uent cause of (le.ith in horses.
Ha'niorrhage is the most common cause of a fatal ending, yet
Dr. Homer (iage consiih-red that 14 per cent, proved fatal from
peritonitis, caused by the continued presence of lilood in the
periunieum. Dr. Hogaiih J'ringle. who contrilmtcd a paper
to tiie '■ Aiuials of Surgery ' (a ])a])er which is full of interest
to the surgeon) on traumatic hcjiatic hiemorrhage. considers
that, if the severe cases are to he got through at all. the opera-
tion must be an imnu'diate one for the majority. That some
of these cases can be saved is shown by the statistics of Ferrier
and Auvray. and by the ctises which arc ])id>lished in the
literature of this country, though these are few in luimber.
Ho suggests thiit when the peritoneum is opened, the hc])atic
and ])ortal vessels should be immcdiati'ly grasped with finger
and thumb, and lield by an assistant whilst the elTiised blood is
cleared from the peritoneal cavity and the necessary manii)ida-
tions are carried out on the liver. He has jiractiscd this in two
cases, and says that jierfect control of (he bleeding areas of the
liver was obtained and a clear lield for operating.

There can be no doidjt that at the operation the first thing
is to arrest the haemorrhage, which appears to increase directly

m

Till

H

'■ A' r TK \I!|)(>.M|.;\

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■"" |"'m<i|i,l|iM IS ..iMiiril III fl„ ,1 .

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Iiom ilic ,.||,,s( „,,||

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•"■'■■' "llr.t,.,! ,,,..,,,11 |„.

■"■'■<•>• I ''"i. (I.r., ill ,|„, ,„,,
.i'"''V nf ,,,s,.s a l„u<r sl.i|,
"' ••'-•■."lie .;.•,,„/,, s|„i„M )„.

""^ ^''<'"M l.r ,,|.,c,.,| in
I'OSII...., ^r,.,.l|y. |.„t fin..lv

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, At-.n-i^,. I,;„.,.,;„„,„ ,,(■

• 1,-'' : l.'ij
■•l'it;il .Mummiiii.

SI. T

l'illl:i> :

••"•lint |>ni|t,)rti,..i(.,|
'" "i<- size ,,| ih,, ,,,,.j,^,

''■'"" "''*'•'' llir l.l..,.,li,.;r

'■;■""- MMSS..S .,,■ .„„::

■^'"'"''I '"•< !.<• .•..,,,|„v,.,|
;"'"■'■" '■^'' .•..ll..'si....s ton,,
''••'"•'••'I infest i„al ,,,j|,
"li"-l, ...aycMUs,. „|,s),„,.,i,,„
'•"'•'■ ' l""v.-l.,„| ,„,,,„,,,„,.
'"'■^"••Ii ;• l;.lc (■....., ,|j,,„j,,„
"• "• tiv;.ll.„.,|( wl,i,i, ^vas
^"•••vsstnl ji, savi.iir ij,,, j„
•'k' first place.

''"'"■'■'■ •"'■ ^"""f wonr.ds i., „l,i,.|, it i 1 "T; .
''"•^■'■at i,.„. a..,| 1 1„. ,.,„„|j, „,,,,.'"". '^ "•■"'> ■•'<'c,..ss t,. t|„.

-n.i-i. A. va.,a,..;'i;;;:,i:;i':^r''''r-"^ «'-<■'•"<•

^^ffT? :^^ '^sit''?^?^as!Sir.s^

rnMMvvu iivnruK (»k tiik vis. K|;\ ,7

;;::■:;' "-"■^- - •■ '-. ......... .. ....

Sin...- w,.iti„. ,|„. ,,|,„„. ,,„, ,„„„^^j

^ -----'. ':::..:::v.::;';,;::!;''i:;:;;;^^

^l"n":::^;r.l';,;;'.:v'7:;'••'"••;■■v- .i-> , ,,.,

II. Th.. ;,i,.i„„.,„,i „„„ : ' "' '' ' •'""" '" i-'"'^" )>■>'« ^Mi.i ...,v

..• I wi," ,;,:,'■".;" ";• - "> > ■■' •"'■• -"'

1. , . ' '" •llll\<ll. Ills . ■(.11,1, •iiMl II,.... .... .. .

I

i

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III.

"'I''""" ""■•I VVi.s .,1 ,,.„„ ,„.,.,

'"•■ '"».i iil.s „„ III,. ,i„|,, ,.i I '" """ *^"" "' l'."'i "V...

-. v..,;i,.,.. J : .^ ,;,;"" '"•--'■-•-■ .1....... ii... ..,1,,

K 1. I- was Mv...lin. ' ,: . J ,; , '" "■"^" '"'"■ "" ""'•"" "^"^

vvKl. .-.sp.r.ii,..,,. ,1 „:,, ,„.,,, ... / '-'"'■"-"■-' ""-V...I v..,.v I.. 1 1..

'•"-H..ll...s|.,s;i..,..,|' """'■' "'"' ""■ l>->,"","'«<nun. M,. M„„...,.

ill...(l..ll
" II w.is .low .'V l(l...i| 111;

i..,.s..,ii. ,„i,i III,. „,,.i,, ;',' ;, 7'"'-">iM(i.i;ii„i„„„„;,i ,,.,„,„

'"Il\ .lis....sM..I. \Iv ;,..„;.. '^'-I'"-'...,,,.;.! hM...i..,.|i,.,. „us

l'>i;i..i..|i „r Wi.isl.iw .,,,,1 v.lil • '■"■'^' ' "'.^ ''-I' '""'fiiiK... ..II., 11,,.

";■ "''■■- <-'«::^'":^.:::::^:z:^:t:\;r:^:z ;

l«'a... anil <.,iii..|,t h,,. |,„,, . , - ''"' '""" ••'"'' -"''• "' iIk'

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"^•-"-"- '"-•■' -•'^':-t>i;i::nr;";..:;n,;'::;:;;;

j'//-'7/.»/, MnliralJoiinml. Vol. I., i,. «. ]!

M).

^£j1

r»H

TIIK ACITK ABDOMEN

n wiiH wa^iiril '■!

"'.ill. lilt i:iv('ii<

was I, nil, ,|iy. Th,. |M'iit..M,-iii
iiilusioii oil lalilc.

A ilrainai:.. liilir wa. IHI in 1 1,., hrpal i.- p.„.,.|, loi 1 1„. ti,s, ini .lavs
"" N"ll,„m,.-.rai.r.| lioii. ,1, an. I I Im- «„iiii,1 hralr.l l.v lir..! iiilnilioii
l.x<;<'|'l tnr a .iiiioiis lis,, ill l,.,n,„.|atiin. ..vri v .■v.imio' nip h. In-' ) ll„.
I'""<'il nia.lr a j.,h,.1 i,...„v.t.v. aii.l «.nl Immim' «,li fo,iii...i, ,lav. aft.-r
ilH' iipcralHiii.

Moihilih/ lift,',- Hiiithiir i>( llif l.iiri:
May.T .
Killer ( ISMT)
I'larlikcl
'1 illoii ( Kill,-,) .

Olll 111 L'llT IMS,-.. Hfiti per rclil , lalal.
•"i47 .. Hrill
.•II .. 4.-. 11

ThoU-lhnihiij ijiirs the mortal, 1;/ nfhr „i,f,oliuH~

If pciloiiiu.il .lining III,, liisl (w,.|v.. Ii.iiiis. .-..-, p,.r ri.nt.

If piTliPiiiMil iliiiiiij; t|„. s..,- 1 uvclv,. horns, (i7 p,.r,.,.|ii.

Iityi»ii,l. 7H per (.(.lit.

RrpTUREs OF TiiK Gall-Bladder AXD
Biliary Passauks.

Traiiinatio rupture of tlu- jiiill-l)la.l.lor is a very raro aeoidcnt,
but IS occasionally seen. If the bile is diffu.sed "throuKliout the
peritoneum there will 1h> evidence of free fluid slowly increasing
witfiout symptoms of luvmorrhage. There may be an injury
of the hver al.so. when the symptoms of liver "laceration will
mask those of injury to the gall-bladder. Of t)ie few cases
which Jiave been published the followijig is a good example
III which the effusions became localised.'

'I'll., paii.nl was ailniiil,-.! into Casli,-! rnion Hospital uimI.t Hi.. ..are
tit I>r. 1. Lathiu. .-.ill,, w.is a inaiiif.l \v..iiiaii. aj:.>.l .".li v.^ais, wli,. had
Ix't'u ti-o,l,le.i on by a .'..w whi!,' in th,- art of niilkinj. it .s|„. IVlt
.sonu-thiiij: «iv.. way insi.l,.. an.l alt.-r sutlViiii;: for so,iii. tini.. from all
tlu..synii.t,.iiiso| a.Mit,. iiillaiiiinatioii wass..nt to hospital on S,.pi,.nil>..r

On a.lniission ih.. i.aii.-iit was in an alarming' stai.\ Im.|ih' almost
nionl.nn.l. .sh,. was i|,.,.ply iauiMli.M..l an.l all tli,. svmi.t..ins of p,.ri-
toiiitis w.'iv pic.s..nt. 'Ih.. ..(riision was. how,.v..r. .•ir..u.iis,.ril...,l
pivscntiiifr lh(. appcaran.-c .if a (•onsi,l,.ial.li. tumour in th,- ..iiifraslric
an.l a.Ijari.nl ri.jri„ns. Th.. pali<Mit w.-.s put uii,l..r chloroform, ainl with

""■ """'"'■■' "' ""■ ■''■ "■•■••>.n..|l. Dr. <;. Cook, an.l o!i„.,s laparotomv

Wiis p,.rlorm,.,l. A lai;..- .|uanlily of l.il... pns, an.l s.,ni.. Iii,uiil fa'.'al
iiiall..r W..1.. .■vai'iiatcl. '11,,. ..avily was wasli,..! out with aiilis,.ptic

' Lumrt. i;iuo. \'ul. II,, ),. H1I7.

TRAIMATIC Rll'TrHK OF TIIK VIS( KItA

.ill

"'''"' ' " <l'iii"aK.- I 111..' wa-. iiiMil..,!, ail. I I h,. « „uu,l « a> mii iik .1. wit I,

tiK' ..xr..|.ii<.n nl 111,. .,|„.|,ini; lor t|„. 11,1,,.. Th.. |.ali,.|,t was s„ w.-ak
iiml III,, pans iM-iiiK s,. iiiatl,.,l as l„ „.,,uii,. a ivmilar ,ti>.,.,.| i,>ii i,.
Miiiav,.| 111,. |.,„„i „| ni|.liii,.. it \vas,l,.,.,i„.,l Ml,,,,. |„,i,l,.Mi i,, mali,. il an
..|.,.|ati..ii ,/,■ ,/,.,o- hn>i,. it ii,.,.....a,v. 'rii.. i„.,.,.»ii v !.,i a m,„>„1
<.|>.'iali..ii. Ii,.w,.v,r. <li,l ii„i aiis... as ati.i' an ,ii„.v,iil In! i„.m,„I Ih,.
vv,..iii.l ,.|,ln,.|y ,-!„s,.,l, all .lis.ha,,,,, ,.,.;,„.,i, ;„i,l Ih,. pali-nl ina.l.. a
li|.ll,.<'l i,.iiivt.|y.

At first film- is usn.ijly shock witli faintiicss. luTliaps local
pain iiiid vomiting, an,! a slow accuniulatioii of liiic lakes
place- in i\ui ]HTitoiical cavity, with prodiicli.ni of limiting
jjeritonitis anil the ilcposit of mucii plastic lyiniih. .lainidicc
may appear early or late, and hilo is absent frc.m the faces.
There ajipears to be no imlicafion for immcdiat(. op(. ration,
and when operation is |)ei-foriiied. it is usually for the evacua-
tion of fluid which has accumulated on tli,."ri<j;lii side of the
abdomen. The abdomen i- asymmetrical, for th,- iiile is never
generally diffused in the |»fritoneum.

If the ruptua is quite recent the gallblad.lcr may be
sutured as in some .-ases of cholccystotomy. Jt is iisuallv
safer to drain it. or. t'aiiing this, place a tube ,lown to the
ru])ture. paeking ofV the j)erit(HU'um after it has bc.-n clean.scd.

Ruptures of the bil».ducts are very rare, and openings in the
eommcm duct can very .seldom be "round. Those which have
recovered have iJecii treated by asj)iration of the colL-ction of
bile which has formed in the peritcmeum. and this operation
has been repeated on more than one occasion ; Imt. if it is
consitlered best to e.xplore. it may be possil)le to suture the
duct, at lea.st ])artially. it it can bi' found.

Henlin is said to haA<- recommc'idi'd abdominal section in
these eases in 1707.

If the ojKMiing cannot )),. sutun.d it woiii,! be best to jilace
a drainage tulie down to th,. dii -t. pack ,,11 with gauze, and
perform a cholecystenterostomy. If the pati(.nt is' vi.rv ba<l
a temporary chol..cyst ostomy siiould be done and later the
junction made with the small b,.w(.| ; it wouhl also be well
to iiuii.,' a lateral communication iietweeu the alfetent and
efferent portions of the l,)op selected.

Only one example of this injury has come under my immediate
care, anil in this the impression given by the slowly increasing
collection of fluid was that it was very heavy.

M ^1

r *
I i

HO

THK A( ITK AHDO.MKX

Traumatic Jiuphne of 1/,p Common liiMncl : lajHirofonnj.'

A 1.0.V ..K.Ml Ji was a.l,.Hn...l t» (lu- |{..val Fr..,. ||,.s,.i(al .... Am«„m Ir,
IH .1. iK.v.MK slHMllv l,Ho,.. Im.,.m I, in »v... I.y a \um.L ral.

H.' was a w..||..l..v,.lo,M..l la.l. snilVn-a' >lj>.|.llv Inm, .|,..,k a.nl

••""■PlauM„K n s,,as„..Mli.. pains in ,1... a...lo,„..,.. ' -,1. .Iv „...,k

mj..ry uas^h^l.. K,a.in« of ,1... ,kin ,.u ,1... Ih. .uU- .., ,1„...| • ni, ^

' '•='"« -I' any .loo, . T..n,,.,..a.u.v i.T-.i . Ti... alMlo„„., «a
not. MKMl ali.l no sprnal lrn.l.'ii„.ss roul.l l.r .-liril...!

On il„. i(iil, lu.s,.,.nu..l taiily W..II, hi.t still j.a.l spasms of pain in Ih,.
.• -.. . MHly on ,lu. n«h, snl.. Unuu, ,1... ni,h, 1... I.a.l I. '. | '

t:::j::i;:i::t::r' '"^ • ' ••'^""" -,..a an.. „...

H..m"i on Jli' '';;;', ""■ """h ' '"■ ''"" '^■'"*^ "" •'" '""•'^ " '"' ''i^ "'*«!-

o I ..'/""■" ' ""■'■'■ ''"' "" "«'''■'>•• '•■■'"'•■"'.■ss. .lis„.nsi:,n.

alh-.ai.on ,n !„■ p..,russ,on not... II,. v„,nit,..l twi..,. a.t.l l.is t,.,„
p -ra ..,.. ..... to Un-> . r,in... sp. ,r. ,,oo„, v,.,.y ...i i,. ,.olo,., „ .

blo,),l ,(!• albiuniii pn'scnl.

IHlh- .siill r,.stl,.ss. witi, fr,.,,,u.nt vomiting: l.,.w,.|s hav,. a,-l,.,l

^.-rj III: vom..,.,l lo„,. ,,„H.s. J.,.s.s ,.,.„.plainl of ..aii. IMdnst
...nponm.,-,. l.Mfo . Th..,v was n.,.„. von.it in« on tl... 2.,, . a o.;
J "Z. ot uf.n,. w,.,.. pass...l. Slight .luln,.ss n..l„....l „„ ,i«h, si Ic ..f
al..l,.M...n. Tl... t..n.p,.,at...-,. ,li,l n,.t ..v,.,.,.,l ..)«.4 "

<»n th.. 21st tl,..,,. was ,.vi.l,.nt .-hanK,.. II,. look,..l v,.,v ill «i,|,
M.nk..,, ,.y,.s. was ,l,.,.p|y ja„.„li,.,.,i, v.„.,it,.,I f,v.,„,.„tlv i,, tl,;. ,.„.m,|,.s.
•nann.r ..1 a pat.ent w.th p,.,itoni,is. Jli,s p,.!., was',api,l a, , .- k
u".i .'".a...at.ou was „.ark...l. Tl... al..l.,n...l,. l,ow..v..,. was . .'.at-
(list, ns,on ,t «as la.,;..,, than „o,,.,al. n..,v,.,l will, „.spi,ali,.n l,„i
W y ,n the upp,... pa,., .as ,.,„ sightly ,..,.....,• an.l w.H,: ' I
K.. .ty (.,. ,„.,-,.„ss,o„ ,1,,.,.,. was an a...a ..f ,l„l„,.ss ,.xt,.n,li„„ ,,„,;
'1" J'.'pat.c. ,•,.«„.„ „.,o „.,. ,iKl.t ilia., fossa ; tl„.„. app,.a,-..,l als.?,

.X .,!...! lorwanls to th,. ,igl„ li,.,a s,.„.ilu„ar,s. an.l .ha,,....! I,ut

« " nnjr th.. ..xan„.,at,o,., was .■,.sfl,.ss. an,l ^rav.. an ......a,;i.„,al .1...,

siKhinjr insp„ati..n. Th.. t.-ntpt-ratu,-,- was <»7->

Th.. Hni.l in ,h.. ,„.,i,o,„.„„. was s,.ppos,..l ,o' 1,0 ..xi,avasat..,l bile
«.lh so,n.. ,nfla,n,„a..„v ,.t,„sio,., an.l ,t was s„ppos,.,l that t„. . .a

-. 1 .' Kal|.hla.hk..-. WV ..ould ....t obtai., p.T.niss.on to ,.va..„at.. 1
»nt.l U p.n.. of the 26th. On .neisio,, through the pe„„.ne,.n. ^vhi.'h

' Tiansuctiuiis of fliuical Society, l»'Ji. p. m.

TKAlMATrr lUTTl'HK OF TFIK VISCKKA

i'A

Wils Miui.r.l n .1,.,.|, yrllnuish ml. a latKc -|iialililv ot |Miir. ,M|.n,,l...s
'III. ran away. Tlir iiil..siiii,.s wn.. roiii;.>l...l. I.ut I !.,•,.• wa> ih.
.VMii.li ...1 ih.-iM. A .liain wa- plaml int,, i|„. ,,,,;„•,. Ii.>ni wlii.li 1 1,,. I.il,.

la.l roMH'. Ixit no altcni|,( ar IuII.t ..v, ati..n was iMTUiillcd l.v Ins

l>a<l Kcucral conililion.

II.' .Ij.'.l on III.. L>Htli. a|.|.ar..nlly In.m ..vliaiisiion, liil.- was i ni

li«>in III., in.ilioiis only on Ih,. hi.t I wo .lays of ih,. illn..,s. .\| 1 1„. .„„,.
moiln,, ..vaniinaiion lii.. wliol.. of Ih,. Miiall ii.l..sl ni..> w.r.. fonn.l
ni.i...'l...l. an.l I.. Iiav.. on tli..n, lay..|.s of Ivn.pli : Uiis was ..s|„riallv
mark...! ..n lli.. li-lil si,!,.. 'n„. |jv,.|- an.l «alll.la.l.l..r w..... inla.-l l.iit
alH.ul halt an iii.'h l...yon.l Ih.' jiin..|i..M of th.. ..vsli.. an.l li..|.ali<. .lu..ts

"' """"" '"l.'.ln.'t was f.Hin.l (on. .•<..n|.l..|..lv a.ross. hm tj,,.

ap..| I 111., was .liili.iill lo lih.l. \o oi hrr I ia..<.s of injiny wviv .liseovor<.U.

Eriianlfs cxiMTiiiu-iits ur.. of iiiti.n.sf as sliowiiij,' the (.(Tcct
of tli(. l)iicilliis ...)li (wliirli is prcsi-nt in the {omm.m l)il(.(liicl)
on tli(. iHTitoiu'uni. wlicn nii.\»..l with the i)il(. .ttc.r its (.scapi.
from till' hiliar\ jja.Hsagcs. both in the j)ro(luction of a plastic
peritonitis and the ])rt'Vt'nti.)n of clioliuniia.

RrPTL-RK Ol THE SPLKKN.

Hiipturc of the spleen is mostly met with in malarious
districts, where it is so commonly diseased ; it may also occur
during the course of an attack of typhoid fever. In this
country it is nearly always the result of a severe injury, and
none of our n.conh'd (.ases of operation have been for rujiture
of a di.sc-ased spleen, so far as could be ascertain(.<l without
micros<.o])i(.nl examination, [n one instaiici. which Dr. ('.
Whwn has found in our nu.dical publications there was
evi.lence ot disease of tiic l)lood on examination.

it is unn.< cssary to ent«.r to any extent into a consideration
of ruptUR. of the diseased splet'n, for although it would be
interesting, it would be chiefly so from a medico-legal point of
vic« .Much of interest on this subject .'aii be found in ])ap(.rs
by Dr. D. (J. Crawford, in tlu. /tiiliini Mrdicul (Iniitte (l!M»i>
and l!M»(i). Som.. of the accounts given tiy m(.di(.al tneii in
charge of hospitals in tro})ical countries, or by those attending
ho.si)itals where patients are admitteil from malarial districts,
are quite startling. A i)atient with a large sjjleen " turns in
bed."" is ])layfully "dug in the ribs "" by a jocular fri(.nd.
.somcotic throws a. grain of muslard seed at him or fii(.ks him
with a cane, and death ensues in a period of time measured

ill.

If

fil>

TfFK MVTK AMDOMKX

l>y .M.M„t..s. Pl.tyfuir «iv<.s s..vn, to ,.iKht ,ni.,„t,.H as tl.o
av..n.«.. .luratioM of lit,. hIKt n.pturr .,» a r.mlari.l s,,|<.,.„. a.ul
tl... lal,- Mn«..nn(;,.M,.r,il ( 'null Ma.k.'n/.ir sai.l that (in !. ,„.r
'•<•">■"• Ins rasrs ,li,.,| ...hI.t halt an i,.,ur. It tlu- alMJ,,,,.,.,' in
.■xan.m.Ml aft.T ,l..atl. it is fnun.l t.. hav I,,..,. ||no,|,.,| with
'•'•'"'I-'. ,t 11... sac ,.t a., atinirysn. „f the aorta l.a.l l,„rst
""" ""• I"->»...i.Mnu. TluTv is ,a.vlyti,n.. for n.or.. tl.a„ a
guossas to tlu. .auso of ti... symptoms ,m..„. fur Irratm.-nt.

Hardy is the rupture of a
malarial spleen survivt'dcvfii
for a few days.

I>i-. White Hopkins, who
spent some years in Sarawak,
has l)rouj;ht to my notice a
weapon whieh I have callecl
tlu' " lethal eross." huf in
Malay the real name of
which is " larang "" (meaning
forhidden). He says it is
used only in soufherii Chijia,
and generally in the .Malayan
countries and islands. Malay
.States. Java. Sumatra.
<Vle))es. ("tc. The weapon
is unknown in northern
China, for the reason that
'"' <'iilarged .spleen is not so

iiiir-nZ:J li:::;;":^ ^•""•"•'" -^ '>> ^he southern

or tropical portion. It i.s
K,.,. ir : I 1 lioavy and made of an iron

bar f, niches long, w.th a -.oss-piece. the en.l. of whic
un.towar.ls the point. The blunt end t-wninates i . a ,t
^^l .1. gues ,t a knol.h,.,l app,.arance. It is ..arri^d
;;"•' "H- shaft up the arn, of a long sleeve. clut,.he bet" >'
t K. second ami .Innl fingc-rs at the cross, leaving the k.mb
cxtcndn.g. It cannot be seen in consequence of tt.e si.cn
S.HU- of the sleeve. The ( 'hinaman waits for his vi n ^^

l>lo« in the abdomen, not bemg particular as to the exact
part wh,ch he strikes. The victun wuhout a groan falls Zd

I'Ki. (i._Truiiiii:itir I.iKviiitiiiM iiii.lCon

tllMoM ,,f the Spllv,,. l.'Hiiiovc,

fliain

MllSOUIIl.

TRAIMATFC RirTlRK or THK VISIKK a

»;:{

N

'"' tiN. spot. Hi. pockHsan- rill.Ml. an.l nmluMK »'..,,• i
Known ttt Ills iissiiilaiif.

I)r Whit.. HopkiMM n.l.ls, '• fr„n. ...y ,.xp,.,irn.r i.. Sannvak

un ..nlarK,..l spl...., an.on^st .1,.. Chin... ,s f.a.n.l in al.uut

■•<'l'«'r <.-Mf. I wn„l,| p, »„rth,.r, an.l sav thai ..v..rv China.
""'", /'"^ '"' '■"';">"'•■•' N'l'-n. Hu. th.. ratin ..f ,.„|ar,..nH.nt
wnul.l h,.as.„ll..w.: Th.. whoh- -f ,h,. ah,h.,n..n invnK,.!
^MI 1 a hur.l ikmIuLmis .nlarpnn.nt wonl.l h,. tin p,.,. ,, „!
IHThaps „..„•(.; a partial ..nlarp.nn.n.. ....npvinu thn.

.iuart..rs „f th- alul,Mn..n. woul.l h- h],.,,,, ^ p..,. ,..,„
'""<l <!'.• r,.n,ain.h.r, tmm a halt t., a .piarfr ,.nlar«..'.'
"»••"!. It a CInnatnan is f.,„n.l Mith a larany np..n him
he IS at cm..,. tn..,| and in.pri..>n...|. l„.,.a„s(. it is kn.nvn what

Vi,:. 7._Tlie \

jiriiii;:.

int.nti.m ho has. It is ,ar..|y foun,U.x,...p, ., ,h, ,,,,. .,f
mt..x„.at,.,n. or tlu> tin.ling ..f a Chinaman in clos,. pr„xin,.,v
to a (load man. ' •

1 do not know of any other ijistan... in th.. hi>torv of tho
JK-opies of ,h.. worl.l in whi.h sin.ilar a,lvanta«.. has I.,.;.,, tak.-n
by t ... ..runn.al .>f the pathobgical opp.,rt..niti..s of th, district
ni whieh h.. iiv«.s.

Rupture of a normal spleen is foun.l as th,. result of ,.onsi.i..r.
able violence, and is met with .lini.ally „„,l,r two ...n.litions
J^rom Its position und.r the sh.It.-r .,f tlu- rihs, wher.. it '
well guanled. esp,...ially in the a,,lult. it is a eompara,iv..|v rare
"ijxry it IS not sur,,rising to find that amongst tl... puhlish,.,!
.•as..s th..re ,s a„ un.luly iarg.. ,,r..portion of voung p..opI..
whose rih.. are more elastie an.l yi..|,ling. no h.^s than fift .e,;
out of twenty-thn... being un.l..r 2n y.-ars of ag... ....arlv all

whom were " run over - i,. ,h.. snv,.ts. It was fornH.Hv lu-l.l
that there must be adhesions between the spleen and diapiira^m

^'^ I.

■i I

Ilii

111

IIIK \< I IK \|;|MiMi;\

'"'"" "'l""iv ..Ml i.ik,. |.l.„.-. I, ,11 .In, ,1 , I,.,,, „ .1,^

'"•'V' '" "■""' > •• '«"i""<v ..1 .1.,...^,;,, ,. „.., „|„^,,,

';" '' ''"''"' •'"■'""..■. I,,,v,. n |..„„.l .Ihmmu ,n,..>„.s l.v

Vm.s N.mII,. .I„.Ks..„, |» \,..x !•.,„, . .,,1.1 nilMM Tl,..,;.

•■'"' ^"""" ''""'^ '" " '' '"'• •'- -"• <-• I'M.- I.,... I, ,„..l..„,,...|

■'"'•' ""■ '"''"> '"" ""•"•' <.l.v. II..' hi...,. ..I 11,,.

•''"'"'"" ^'^ ^:'*''" '" '•"• f,,..,! .1,.... „..| .,!„., V . . ,,,y ...„x,..

"'"; """ '•'-'•-^'t'....^l.«,.s .„„,.,, Sl;,.,.|,... ,„, ,lM.|v|.,n.

"I linl'' v^.ln.. I..II K.ll.., ..,„„,„„.,. I ,1... iii.„(alilv M sj:i ,,..,•
.■••Ill I.I ill.' ...1. .iliiph, Mir.l .MsiH

I'll.' -M.ipl.Mlls |.|.m||,....| „,,ix |„. i,„„„..|,,,,,,, .,,,,1 ,,|,,,.,„„ ,

"•■ ll..',^ 111,1V l„. .i..|,,\,,| ,„ ,|„.,r .l,.v,.|..,,m,.,„ |Ju,.,,,||„,,:
M..........! tli..|., „,, ,„ ,1,,,,,, „..,,|, ■■ ,.,r„.„u.0H • r/n„„„

''"'"" " V/"'"/"' l".l I....I K ,..|..,„,| ,., ,1,., ,.„,,,,„,, .,,•

■■' ""•'^•"■'' S " l{..|.l....- ..I tl„. I,l;,|;,n;ll s,,|,.,.„ ,„,,v |„.

''"'"''•"■••'' '" ""• "'I'lu..' ..I ,111 aii..|.,\ M... ;,„.! ||,;„ ,,| a ,„,r.,„i|

^|>l.',ll I.I III,- W.I, 1. 1. 1 .i| i. I.il-i;,; ,,||,.|\

I'Ik' am. .1.1.1 ..I sh.i.'k v,ii-.,-H x,.,'\ .'..i.M.l..al.l\ «|„.„ h
lirallliy s|.|,.,'.i has h.M-,i rii|.i „r,..l. a. ..I .|.„.s i„,| |,V|,, ,„ ,|,],

.ha^MKisis. h.it I a... i.i.'j I ,,, ||„„K „ ^,,,,,|,,,. ;,, ,, ,.„|,, „,„,„

Ih.'s,,!,.,... .allu-.' I hill. wli,.,i 1 ... hv,.,' has l„,..i ..,,,1 ,.,,■,! ,i„|,..h
"'"■ I'l'vial...., ..I iln- lall.T .s .h'.'p ,.,■ .-m.-iimv... TIi..,-,. ,„,,v
h.' .... I.Hal .'\i.l,-,uv,,| ,'..„i„si,.„. |„,i ,1 ,|„' i.ijmv u.,s t,, d,",.
spl.Mli.' n.m.M.. ..l..,',.,-p,.,.,;,||y ,1 ih,. .,v,.,l\.„i; nhs'a.',. h,-.,k,.„

ih.'Mlh,. ureal p.-..l.al.ilil.v is th.n tli.' spj,.,.., has I „ i,,,.,,'

aii.l tl.,> s_\mpi.„„s «.!! 1„. .ho.k ■ ,,„■ h,,,,^,,.,..' ;,,„| ,,„. • ,J
«i| lri'(> IliiitI III the p.'.'iton.'iii.i

P.iiii iua> li,< s,.v,'.v. I.iil ..II tli.'.,||i,.|'li.ui.l it ...as 1... ahs,.„|
i.M.lth.'ivmay.-x,',, 1..- .,.. t.'.i.h'i'i„-ss, Tl.,' .•hi.-l ,','.|i,„„.,. ,„,„,'
h<' pia.',.,| .„, th,. p,',.M'n,v .,( |,io.Ml i,, ih,. p,.rii,,n,,,i ,.„,j,v
S...M1 atl.T a., iiij.ny. .i.kI ih,. p.,„.ral ,.|r.','i „| H,,. ,.s,,.,.„. ,;,■
tins hi.„Ml ..I, Ih,- pati.'iil. h is strans:,- H.al i„ „,a„v .•,.,..,r,|,.,|
.'xampl.-s ,.t n.plu.'.' ..) ||„' sp|,-,-„ ,1,,.,.,- is „., siat,'.n,'.,| as i,,
th.- p.-,-s,.n.v ,„• ahs,-ii,.- .,)■ ,|„iM,-ss in ||„- alMl,Mii.-ii Auy\u^ ,|„.
pr.vuMVss ..t th,- .as,-. ..r. in lad. ai.y ....i,- i., show that tli..s,- i„
i'l.ari:,- wore awaro ot the voiy larm- a,ciim.ilali..ns „f h|,„„|
vvhi.h w,-.vn'voal,-.l al th,- po^l-morU ,>t ,-xamii,.ni„„s. |„ „iu-
«r uso ,as,'s. in wlii.-li ,.p.-rali..ii was p,-rf,,n.u-,| ahn.a,!. il is
stat,-.l th.-n- was m„ .iulii.'ss. aii.l, a para>;i-apli .ir so later .».
that a-n-at .l-a! nf hLnnl osoap..! uhcu th.- peril,..,,-...,, was

ft

P I

I I

t.,»./i>..;-'T7/*LTy

••':M M\T|. |;| Til |{|.; mF I,,,; M.,,.:,M .. ,

!'m!T;l II '^'''7::' ?''■'■•' ''''••■"'''•■^^ ^ '••■ '•■

'"' '"^"v V'"^" ' ''" '"-'-•".-■I I.,,, ,.

•"••■'"; '" '"•■•' -I- - — ,1 .,, „,:

HVIII|.(ulll, ..t I,, , ul 1,1 1

; '•;'"; "•"•-•i.-- n... ,i,.,., ,.,„.,.'.' ;:,;

7';'' •'''"'■"•" ""•*''"""^'"" ''"•-',„, hv.M.n.l,,..!

^lill.' ul III. |.,|(MHI |,l,r,in..lH

''''"■"'"•""«""'"— I""' i I. I.M.„n..M|... I.,,,.,...

lll.-ar,...|..M|. ' '^"'^ ■''•'■••

IMI...,MIM.M, .„n. v.... n.l, „...!,., . ,„„ ,,,,,, ,,,.

'"^' ''^'> '"■ '"" •" 'I'" ..iImt ;,),.! „. „.,l ,, , „.,, :,

.lHl.-n.,..n.vu,„,.,„^.,,.M„, ,,„„..„....., „n.l„,l„, v.np...,,, ..T

'•■"•«•• '•""^'-"-"» 1,1 itilull... ,„.,„..„..„,„

I< '-H.lvis.l.l.. to r,.n,..v...lM.s,.|...... ,.,,.! ..,M,.,v .!,.■ ,.,.,i.

*;:•"•' •'""•'• ' -1....I. I.M ,nv,..|...M. Tl... '...„,„ I,

..II N.s..„|,.tr or«.„ „...;., ,.n.s,„n. , ,.,„,„,,. ^^,^

i" '7 ;;r <•''';•'••••■-•' -iM..i. ...... ,,,,,\.,,,.,,,,.,,-^^^^^^^

H|lM,... s.ssris ...n.l so .m...,.,| ,1... I,,,.,,,-,,, I,.,.-,. Sal,,,..

I IH. smMvsstu ,.,s,. ol .vvnsioM tor ,1ns iMjurv. .Inn., l.v |'.n.,.|,
s..r«,..„H. an.l .. k n,.,.n.s,i„. ,,. ,in.l .ha. .Mr C \ •,.,,,.

'^V"; ':'''''''''••"'■■''>■•'''■'••■'•••'•-••■'•'•--''''■'• f'..v I-

.ul.hslH..I ,n , .s n,„
-.•>>< Inall.hr... ..as..s .h.T,. uas MMrk.-l ..,.ian..,„..n

•' <l'<- lv..M.ha,„. Klan.ls a|-.,.ruar.l. .-n .h. .,.,..,.. ":,f W
».o..y. wh..n ,1,.. lu.i,.,.,. ha,| ro,„v..n..| ,n„n .h,- i,.M„...|,, ..
I'tfi'ots of the- iosM „f till- organ. '"M"iiai,

A. A.

m

m

. . : 'W^' -k.

m

TUE ACITK AfiDOMKX

jii

If

is

Hiolfsi,,,, wind, s nivscrif \\|„.,, ,, : ".ituk ot

'"'• *'"■ '^-■•■"■<>" 's of the- iMl.MM ,u..| v,.ss,.|s ..Mt.Ti, . In- tl .'

C=;;:-;'p;lr;t;:;;:;;t';::t'— ^

.111(1 (h,>ii a second iiic sioii nia.lc ..vc- tl„. ..I I "i< ""««••

'n nia.iy of .iHM.nlinary trainnali,. n.,.,„n s this is .Inno a,ul
lias advised a, loni: iiic sion i,, ti,,. |,.^ ..;,i. fi -MniaA

r-:': --•,-■:::■» < »''"--n:™:;;>::;::^

'•'•"'..ved I.cvo„dllu.,lam„s nid in.. ll I 7 '"""'"

•"■^ It IH- f.ss, ,. iM.yond ,s possil.lv ina.i,..,nah-. lar-.T v^.s^ls
' ''^' ♦'''•'•''''''•'>»''".,. sh.udd I,,. s..n„,.ds..,,arafX.
Hincin-: of thi; Kii.mv
'•-"O'^ioMs of ,lu. kidney lea.li.. ,o laceration of ,|,,<
gan are a,non,s, the most ..on.nion of a,.,don,iun i, i„
'"' "■' 7'"""f "f "^ l>'-.tee.ed position ,he extent ,.

«'->.a,e d.n.s „o, of.en ,e,„i,. „,,,,.,, in,erfVren,.e I Ln

""""""""" '^'''''' ''■■■■'-'♦■■-• •'-.■lop ill a pati.it mL;
•--n„...ver,n,hestree,andeo„.p,ain.ofLnhar, •

TRAUMATIC HLTTriJK OF Tm,' VIS( KHA

<i7

:;:i::i::;:;r :r:;;:::;,:;^ ::;::.;r i^

Uw more scvciv injuries ;nc iiM\v..v,.r ♦• '
"•" ••'••'•••"•PHnic.l l.v srrious .lunn. ,' "'"" '^

'>'-i-n.pi.n..,..,,,:,,,,/;\ ; '^ ;j';;'''Mn.t.a„H..

-t..M.lsi„,otlK.p,.|visnfnJlddn.v .,",'■ '"•'"''■'''^
"♦ s„pp„r.1i.,„ p,,.|,al>k, S„pp,„.,H,' ''" "••'■"'•'■<■"<-

'•""'I'"'-""" »■'•<-" the pn.xin ' t T . "" '"""""^

ti-sanH>tinuMiu...is...pi,J,.:: V ;';-:;;.;■"'<-

'''"«licT' f„u,„l fi.af tl...M. cun.usions nf il,,. I i.ln

'""'-•"-^-'- H. also found, IM, .,,'■' '""'^ "'''••''''■•
cases wen. »:! ,..,.,'.'" •'<''"'s.n un, on>pliea,e,|

plualed
"inplieaicd eases death

there were iorly ease -otun.o, '"

cases M-ere t;i per eeiit.. wl.ilsf in the ,

followed in s

inclusive

tf- kidney adnn.ted to S,:TI,onn:-:,ro!rr'l •'';'''""'''" '•'
Nvilhout operation. """""'^ -^ ""^1"'"' "luel, reeover-.l

|"'ivco.l,e,s it was thou^di, advisal.le ,o ,,,, • ,,„! ,.

kulney was ren.oved in four : of ,i,ese one di | ,: "'"
inn. >arMu..su.n was ,nade and ,IH. patient r,.eol;,'''"

''"'•''''■•"•■''''''''''•''''■''•■■■'-•s. tw,.|veinnundH ,1, r
was also ruptured in six (of ti„.se two h,d d "''

I'n'K). The spleen was dso rup • ' ''"'""'■" ''' "'"■

■•--•rcdaf,erexeisiono,,,o, :•;/;:;;;■■ , "^ -'-''

^•'— salsofrae,ureof,h..i: ': /;" '^^ '';-""'<■'•

'-—'-^'•i- ... the ahdonunal e ' ' 7' l'^'""-"

"eniov.-d and w ...n , ■ ' "" '-"I'lcy was

'"""""•••l">^'c into the ahdon.inal eavilv
"cMioved anil recovery folloMcl.

" '■•''l"''''~ con.id.'ral.le fone lo produee ,•

•Aali, (:

M.

Isss

' iiiptMi,. ,,i til,,

F :.'

'tMmiL\'mvEaK^-

If

I

If-

TUE MVTK AMDOMKX

n.':i::;;;;w•;;;'"™"';;^l;:;;;;:::;;7,:;•;-,»]".^ :■•-.■...,„„„„.

full ol I I ;„„1 l,l„o,l ,.1„K ■ II „ M!;.l ,|h. |M.,ll,.,„.,i,n was

the jiiiioiiiil iM'iiijr jncutci- Wui'A
iiliiloiiiiiial visrciii.
rsTi!

'■'"" ""■'•'!'''l""-l<'\c...sin. 1„.s.,M.I.,.m|
"'■■li ^<'>-n a';,T injury I„ il,,. „,|i..r

u.ln,ilto.l<,n .Maivh -'4 I<)|l I, .vi.„ i '"^'■'- ^ «"' •'^"■'l « was

;;,.:ir;."^'- ^^ -^'^^^^'^^^^^^^^^
..;rs"x;:.:;:i;r::i;:;;!;;:i;;;i-t;r:,:-^

a.va on..„,l..nu.ss. Vnm was ,...|..rn..l ,., ,| ,. „ ,. ^^^r, "" ••'■""""

of tlH. alMlonn.n w.-r.. sii.l,,!' nS ' "'"^ "" ""■ ''-'" ^"''■

•"""' ^'""iii'''l ■■< 1 alter a.ln.is>i.,n. al wliicl, ,i„„. , i,

"~' = '''7 ^'"'- '-•■•■ ■' .-.ann.a a , J::^:s

'■•■'•■■■-I ... ..! it..,. ;J!:::,nt ":■':::::;:" ■ ';,;":;7 '■ '•;"-">•

was l.ut slijrl.tlv n.ri.1 Tills ,li„,iMi 1? 1 , •''"'""""••' "••'II

•>"t;ho .i..i„..; in n,., „a!.l:: i.:l:; ; ,;"':;;^,; ;: ;7' '-• -•

tcii,l..rn,.ss ..v.T tin. knlii-v n-ioii. " ^' '•""^'■•'•ia''f.>

MU. an iiinsion was mail., o v..,- , I,., n.iu ,...,•;„. ,n.l tin. ninx.I..

I'I'lll'il.V "t fivsli I.Io.mI

<lis,,lar..,| inwanls. Tln.,v was a oonsi,i..,al,V ,

... .1.0 p.Mit..,n.al .avity. wiii,.|, .ann. t i.n.nU a ;;:;;■;:;/,;" ll::. '

"'V.T tin. riK'lit l<i,lii,.v. 'iliis „u,.inin. w i , '" "'"""■"".

'"' ""''■• '■''"■ l"'i-i 11.11 was ..j.-an-...,

was nil..., witi, ;:au.... in,,av,.n ..1,,,.. I: ^Ju^^'Z ""•'^'""

tion. aii.l an..iwanls salin,. (wi ■,.„lv „ "umii: i In- .,|„.,a.

"':r '-•"■•• "- ■ .'- J;:: ;l:::::i?;; :;;,:::'■';'::: 'r

♦'•''-■.■.^-i.;;..' ;-n, a ,..n,sni..vaNi.: a;::;nr:;/ ;■•:^;;!i,n;''^^^

Operatio,, whc-u muUn-iakru f,.r ,1,.. Uv.Auunn ot a nmt.nvc!

(>!*

"'t tlu. n.a„.,.ulat.,u,s. F.„. tl.is .vas,,,, .shmk- m-.-Mmu.,;!

■. tn ' ; "f "• "'^' """-"•■ -IHTi.w spin... Kx,,,-

>' '»'-<l .I.-.I ,s tn.nMl n.akinu its wav to ,1,,. „„„.,■ sid.
ol <li<' spinal muse,. s. If it [^ ,,.,.. Il.l, •■

I,,.., I v. . .... ' '^ I)I>SM|,|,. .,v,,I,j o,„.,|niir f „.

t'"' t..s,.,a ,.an l„. tlu.n ,,„i..kly n„ an<l t „■ ki.ln.v p<..li. I.

'"^..ual ]„. exact positmn ..f flu- |<i,|n,.v. ft is not mHI ...

'n>l.lyada„,p,.oJnnTic.dlyt..,l,..p.,,i,:i...asth, vn' a
-«y'-njuml. If it isp,.ssi,.,.'t.. applvfo,.. s . ;
-i.nM>-......s...an

.M,l -'n. „ np to ,1,,. s„.,„... as ),Ho,v mnsion in
^ W^^^^^ ;"-'"^'""-"Mnpa.s„,„tin,..,.tin.o...l

M- ii.-k <.at<M.t sutnn.s into ,1,,. snl>s,an,.<. of ,1.. ki<ln.. -

,; 't '"' "7T "'l'^"'- - ^vl-" tlKT,. an. n,anv fra.-
mnts. mnoval of tlu. o,-.an will h. niuH. th.. safoM T^

■ -paratc tlu. nuHn par, of ,Iu. kidney ,uidJv .i,l. ,1... f,,'
'"U.'.. I.r.n. M t„ ,],, ,.„,fa,.,.. and li.atn.v ti,. p..di..|,. viti,
;;;;;;u .nt.opo,,i.„. l.wiin..advisa..l..,onJap i..

■•n.-uiysni ii,.,.,||,. f,,,- thcs,. li.ratun.s

•ml pass tlicni so as to

c.u,x..H.u,.,.„.,- and vessds separately. Tlu. kidnev is eut aua v
out me ..eyond,l,en.. I Ms son.H in.es easier to pas ^^
; ^»*; •"• '•'•'•"Ps kave ].een re-novd. an<l if the kidne^

Millie this is heiny dojie.

If silk h, n.ed fo,. the pe,iiele.tlu.nthe ii.at„res nu,st he
long. hfJaieiit dnujiage must l,e proxided.

left

70

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lit I

III

THE ACTTK AUDOMKX

n£ V :;::,,:;:i;:;;;:,::'::;;;i:;:^:ir-;:r
;,,:f;:;r,,:;:,J'^/;i;•-,:::;;::;:t.-^^^^^

c:;::=:-;;;r^:;:i;-:r:i-
.::;.rrt;::r:;:T'::;;;::r7-i';:r':r;;;;!

agoo.|p,a„,ol.av..soM,.s.,hu.s.,lu,ioMi,nlK.p,.n,onJ..'H;;

lNTRA,.K,UT,.NKA,. H.Pn-KK O,. n.K l-H.NUn- H,..M.,.KK.

. '"<'-'|>f'itn,u.,-.l n.pt.nv ,.f tlu. I,l,ul,l,.r is still a vnv f.tU
^ K H s. . tlu. I,.s on IS .i,a...os,.,|. or llu-n. is n-as..,. ,., ,,. , „,,,

^>t:7;r • '";'^''^''-^^'^'"^^--'-t--^ui,.d,.i.i, :;

• " u o„l. Jn ,|„, ,,,„„. ,, j.„^^^^^^^ ,.„i|,.,.t,.,i 14-J rws

0 .nat(,l , ucrosstullyu, tuouistuu.-.s. al„ln,„i,.al s,.,.,ion boin..
l'"*'.""'^''' ;'"•• ^l- ••<■'" M.fnr,.,l i„ ead. .as. Tl s w t
H.u-lyon..hun.ln..|,.a.saf,c.J.n.jaminl^^^^

TiK- pa.i.nt prol.al.iv ,>,rs.n1s l.i.ns.lf at tl,. l.nspital uitl. v

>n U. MaHonna,. operatcl s„ s,„.(.,.ssf„|lv. thr " pi(„uvr
--- ulu.n lu. first ..anu. to .St. TI...,Mas-s linspital -

'';-^/-'

THAr.MATic itriTini-: or thk visckma 7,

Nvliilsi 'i'".ln.,M., ,.l (1„. w,.,.k wa.nuiMny ;,„;u »,ih ,,,„. ,

;i;':;";f"'""""""— i™..., r. n,;.: ;.,.:' '''^, ',;:;::

MM ,n ,,.aM,„y l,„. , ,„,,. „,,,,,„„ ,,„ „,.,, ,., „„.„,..„'; ^' ^ -

M/. .1 th.. ..ailM.,.., M,u,..,„..l ,1,.. al...,,-,. ni Mu.nu,. .„ ,,,.. ,.,,,,'

. u .n.,.nn..s w..,. „,:..l... an.l w. l..,,,.-! „.„ ,|,.. paU..,,, 1..; ' K i.;

'>»}. Im- liii.l linn hitMsrll iiuuiiiM .1 |„,.i in i|„. .,||,.,. ii,,, ,7 ,

•'.«I.I <l,..,.l,.l.,„nn..l ,...„>, h.,1 .,....„ ',.v...... . i Uu. 1" ,

".''lv:;;:t::;:;::nr;;;.;:!.^^^

llir mil mil... l.la.l.lrrm.MMiiv,! 4 iinhr '

111 li'ii^iili.

T l.avr .hvcK on tl.is ,..,a.,^r,, ,„ ,„," .lull a.vu f.,,,,..! in tl...
ab,l„„u.,i att.T lu. inst.un...„t |,a> I,.,.,, pass...!, an.l ||„i,l Mitl,-
< niwn by It. l„.,.a„s.. il has n..t mviv,.,! att.nti.,,, a,l,.n„at.. t.>
■ts value, as au ai.l i,, .lia,.„,sis. An..!!,.,- UM.ful si.,, w..„|.|

>;• " '•;;"♦;■''*•<';:' rt-f.. m u... i.hui.i,.,.. ,,.,„i,.,i,.K ,.,..v..nH.„,. „f

'*' <'at u-t.r d. l„.ulf, wl.ils, ,„.,.|,a,,s ..„iy an ..mm., or ,wo ..f
l)lo.Hislaiiu..l (iuid ,s witli.lrawii.

Of mtraiH.riton.al .njituiv „f tl,.. |,la.i.l..r it must als„ 1,,.
ri-mM that sh.u.k .s „,„st u.uvliai.i,. as a sv.„,,t„„, : in
S.r W. .M.,( „nnu..s sc..-.„hI ..as.. whi..|, was als., „„.|,.,. ...v
<>»>sman,,,^. ,h,. ,,ati,.„t. a hravy „,an, uh., ha.l tali..,, tnm, a
lin.ht,>t2..h...,i,.asittiM.p,,si,i..,.,,,..s..,,,..,|,,,,,,,,,,,,^^
of sl„.,.k a„.l s., lew sigus ..f i„j,„.y ,),„ ,,„, ,,„„,,, ^,,,,,,^„,_^ ^^
•H'-t al.l. a.ul .an-tul ,„a,.. .ii.l ,..„ (i,„| justili.ati.Mi I,.,, his
a.li.M.-sio,, uutil h. aj.pli,..| again ,.„ tl„. |.,||,,ui„.r ,htv W-t
the ivut m tl,.. blad.lrr Mas i> ini^hcs I,,,,.. Th?s is" -,11 tl..
mn,v„„n-,.sti..g as this i,Mus,. surg....,, ha.l l,....„ „„ ,|u,vwi,l,
th.. lust case au.l tvciguis,..! tl... iH,ssil,iIif v ..f this |,.si,;„

ihv n.sult .,1 i„j..,.|i.,„ „i st,.,.ilis,.,| sali,,,. i„ nicasurnl
^^"""'"' '"«" ""' l'l'"i.l.'.-. Mhi.h is all„u..,l t„ ||,.u- .,„t a.M,u
•nay b. tri,..l. but th.. t.wriug „f ..i,. j,,,,, t),.. ,„-ritou,.„„, ^...v

gi v.. a sm.ms a.l.liti.,,, t., any sh.K.U alr..a,ly pn.s,.„t . ami n.,t hi,,;,
isgaiu...! by,t. Inth.. majority ih,.„. Hill ,„„, 1... ,i.,i,|i, v .ii^

i

"h- l.m..r alMlo.niMHl n,us,.|...s. f„||ow,.,| |,v th,- sv.np.n.ns of

on ll.c (.huMl), ,Ih.v, is a., oxtn-nu. ,,n,„f of this )),■ n,, ,., '

;;: ';:'• '••''■•'77' '"-vow. as a laLnn. an ,.M,i,.: ;,a?:^^^^
' ■ >njurv .vln.-l. was in..„rml ,l„rin« iaf,.xi..a,i„n, a, ul wl

I '<• sympton.s of in.ritoMitis n.ay lu- v.rv insi,lin„s iu ,1, -r
->p.-..lnM!Ms<.lassofn.s..n.,.,.than,Manvotl,

I'" -. ;MHl laf..,.. v..„,iling. ,„ay l,.- ,|., o„!v sv.npt,., J
-..■ns,v,. ,n,M.].i..f. Aslnnst s.at.s tl.al a.non.s, ij „ '

-.-v..n.moxH.at.lat,lu.tinu...f,,u.a.d,l..nttlu.n: ;
^.p....^4.M.n.......wims,anH.gsttiu.sol,.^

TlH. slmok n,ay pass auay .luring tlu- uuvonsnnusu... c.f

noxH-a,,..,, ami tlu> pati.nt know nothing of anv iniu

r<yMv...| u ...n ,n suH. a state. Thnv is a n-tnl of a s. ' i^

-Id. n. who .|„.,1 tVon, peritonitis after this injurv " I-

"•■'! '•;"' '"•«■" .-^ wrong turning when drunk and alien tV n

..n....,otl,<.g.o.nul outside the W^^^

' - "■ - f"vato,.y after return fron. leave. Tl,e eau.e of the
aceu ... was .hs.-overed l.y pJaeing a guar.l over the lava!.^.
S-nc ..aM.s n.ay g,v<- l.-ss definite syn.pton.s. In l,o,"h
1""-Us nn.h.r th.- ..nv .,f Sir W. .Ma.-Corn.a.. then- m-
;;;"..al t...,.rature. no vo.

u , .,utal. lie seeon.l man ha.l h'ttJe pain, l.ut there was
.> d.s <'ns,on of l.la.lder. as there .shoul.l have l.ec-n when it
., ■edonth..se...>nd..e..asi™

d.on. yn.pan.tes an.l th<. pre.senee of urine in the
JH-. tonc.nn, do n... prove the exist<.nee of peritonitis

-\ l)ulien. with this injury n.ay live for five davs. apparently
""l>n.v.ng. an.l then d.e quite suddenly. " '''"'"*'>

Jlcialin, afUr Ope>atio>, for Inlraperilone„l liuptur, of the
I riiiriri/ Jilnddrr.
]«S(;. I'llman l-i:i eases with two re-overies
1!H»]. .Alexand..r and Jones. 54. (Before ISf..'}. a mortality
"t <i:Jo per eent. after :i-2 operations ; between

TH.MMATIC lUPTI UK oK TlIK Visr Ki; \

I'.MMI
li)(>7

-- optTJllidlls.)

AslM.rst. I in. iMtu..,.,, lNi.:!a.Ml |!iu;j. „ ,. urtalil v ..f
4:.*-, J per rrnt .

Quick, iM.. l,,.lw,.rM IN!.:! a.Ml |«M.:!, a n.orlality nf

' '" • l""l-''\»'"y t<. >lu- ..p..,.a,inM ut .■:,.p,.apul.i,. ..Vs.oto.Mv.

«'•';■ "'«■-■'■ -s ,lu- s,.nsatio„ of soMuMlm,. i^ivin. wav as the.

u>.l pass,.., ■nt,. tl„. ,...||„lar tis>„<. an.„,.,l tl,.. i.la.'l.lcT ■ it

t a. .Mj,.,.t.on is ,.n„liMu...l a„ al.Mnnnal suHliM^ n.av appear

''iM.vr th,. pul,.s. wiiid, ura.inailv .linnnish.s i„ si.,. " "

-\M .•xtraiH.nto.M.al n.pt.nv of tlu- l.la,|,|<.r is of,,.,, asso..ia„.,l
w.th a f,a,.,ur..,| p,.K ,s. 1,,., is „o, ,...s„i,.„.,| ,o su.l. ..as...
Jl.cT,- ,s ,1... ins„„..v of a lik,.|y injury a.Ml a, .....Mplain, of
""il''l'ly fn pass urin... .\ ,.atlH....r if pass..,| .o.s i,.,o ■.
'•""f-H'«-<l l.lad.l..r an.l a littK- urin,. is foun.i wl,i:.|, n.av ....n".

an, l,,.,,,| No ,|ul,,..ss isf.,u,.,|i,,tl,,.,U,.|,s.,,,,,.,|„..s'a,iis.
t(;n.l(.,l bla,l,l..r show ahov.. ,h.. p„l„.. a. ,i„„. pass..s. Si«ns
•• n.flanunat-.n of ,!.,. ,...||,.|„. ,,■..„, „,„,„„, .,,.^.^.,, ^^,^^, ^:
.....sf n,ark..,l .,„ th.. s,.!.. of ,h,, ,,.,„„,,, ^|.,,„,,. ,, ^^ ,.j

a'ulrcs,,nation,wifh syn.pton.s of intia,nn>a,ion an.l s,,,,-
jmrafon as th,. ...xtravasa,...! urin,. ,i..,.o,„pos,.s. An irn-uilar

sMvln.K a,.p..ars al.ov.. th,. pul„.s. wi,i,.|, is so„„.,i,n,.s Un.-
pauif... an,l ,s „o, ,|i,„i„i.)„,,| ^i,,.,, th.. I.la.|,l,.r is ,.n.p,i,.;i

OlKTation is tin. only tr,.atn,..n, p,.rnnssil>l,. ; iuL nu.st
consist of ..o.|,o,o„,y. ,vi,h ,.k.ansinM "f ti,.. iM.ri,,.,,..,.,,,. an.i of
th.. ai.ph..ation of sutun.s t.. th.- r.-n, i,, ,h,. l,|a,|,|,.r Mhi,!,
jnuM not ,...n..trat.. th.. nu...„us nu.n.hran... I, has ,•...,,„],.
"-n sujjg..st..,i that a ph.. shouki 1„. pk,,,..! ..v.r th. ku...ra-
t'on n. th.. 1, a.kk.r Mith,.ut sufurinjr of ti,.. n.p,,,,.... an,! th,.

pclviH ,lranu..l through a suprapuhi.. op,.„i„.. Th...... n,av I..-

M.s,anc..H wh..n this wo„l,i 1,,. ,|,, „„,,- ,,vailal,].. p,.,„...,lur;. on
'"■<-ount of th,. .k-sporat.. stat.. ..f th.- patu.nt, an.l it has l...,.„

Ml,;,.(.ssfully i.nii)Ioy».,i.

Jt is n.-oossivry to .lescrih.. n.on- fully th.. op..,.ation in th..
mtrapmtoneal ruptur..s. A n,..,lian ....lioto.uv is ,p.i,.klv p,.,.-

tonn..,l an.l th.. poritont-un. opnu-.l f,...,.|y. Extravasnt,..! urin,.
Av.th I.mt,)n..ali.xu.k.tion is r<.n...v..,l as n.u.h as i.ossil.k. an.l
th,- nU,.stnK- puslu.,| out ,.f th.. way with stmlis.-.l gau/o ' TIk-

74

TIIK ACITK AIJDO.MKX

I

J

IS:

ll!

Tit'H<lcl<.|ilH'rKj)(>siti<)niHiiy he of assistance at (his stag... .\t't»T

tlic rent has Ih-cii localisc.l it may Im> ditticiilt to n-acli : tlu-

iiMisioti must I).- .ani.Ml well (.v.r Ih.- pulx-s. and slionlil tli.iv

!••■ iiisumcirnt room tin- ivcti miis.l.s may Ik- di-taclu-d on each

SI.U-. Silk suturi's (X„. I) should ho j.assod hv means of a small

nMuid-hodicd n.vdle in a holder alter Lemheit s m«-th.)d. ahout

{ inch apart, taking up the juTitoneum and muscular coats

only. Tlit^ end ones should he placed hevond the rent in

the hiadder. which is usually vertical ami" ah<.ut 2 inches

ill length ; all should he passed before anv an- tied. Their

introduction Js facilitated if the .me near.'st tl... ahd.)mirud

incisi.m is pa^-,e.l first. After they have h.-en ti.'.l an injecti.m

iiilo the hladd.T will sh.,\v if the line is watertight. S.mie

surgeons recommend a double row. .)n<' !;> bring the torn edges

t..gether. the other t.) bury the first .)n.' in a broad fold.

'I'he sutures are cut sh.)rt. and the hiad.ler resumes its n..rmal

position. Th.' peritoneum is cleanse.1, especially in the Hanks.

wlure fluid may have escape.l notice : and the woun.l closed!

with.)ut .Irainage. If the patiint suffeis from retenti.m .luring

the after-treatment a sterilis.-d catheter should bo passed.

and it is well t.) hav.' a supi)ly. pr.'pare.l by Heriings most

.'tlicieut method of sterilisation, rea.lv for use.

In cases of .-xtraperitoneal rujiture the space of Hetzius
should be fr.-ely incised and drained for sloughing of the
cellular tissue will follow wherever the urine has gone. This
cellulitis re.,uires free incisions. It is sometimes ])ossible to
l)ass a .Irainagetube .lir.-ctly to the opening in the bladder
and so prevent any further .litTusion of urine. This opening
must be left to clos.- by gr;,nuliiti.)n ; it is seldom possible to
emi)loy sutun s.

J'eritonitis is the nio.st common caus.- of death, and early
operation is the best prevenfalive ; but even in early cases i't
may occur from e.vtravasation ot infected urine; infection at
the time of operation ; infection from a .lirty catheter : or from
an imperfect suturing of tlu' rent.

THK AKTKH-KITECTS OF ABDOMINAL IX.irHIKS.

Jt usually liai)p.'ns that when a patient has survived the
immediate effects of an abdominal injury his conditi.ni rapi.lly
returns to the normal, since he is in exoelient health at the time

,*~■*i^.•

AITKIJKKKKCrs (>K .\l!l)( ..\l|\ \L |\.|||{| KS 7.-,

«'f tlu-HmH..,,t . an.l his vilali.y has nnl I,..,.,, s,.,.,,,.,| |,v imviuns
«I.M-as,. or |„ul...,.:,.,| illlM.allh h.-i.c.- n.MvaIrs,-,,.".. is rapi.l
""•I ••'■.•nv..,y .o,,,,,!,.,,, N,.v..rfh..|,.s;. iMJuri.s to .hr ah<lnn,...,
nrv 11. .•.Ttairi ,., ;,.s hahl.. („ |,,,v.. h.-hi,,,! th.in fra.rs svhi.l,
snmHy nnl„.,.ahh. at first. .„■ ,,.,ha,,s „nl apparent at all
lacr..Mac(,inr..alarrMii.-prnp.,rti,,„s, Th.- nuiiihcr ..f patients
who si.tJrr tr..n, .nrU s,.,p„.|a. is „,, ,|„„ht small .•,MMi.l..ri„u
H.f«r,-at tr.M|uc.uy nf al..lo,nmal injuries „l all sorts., partiru"
l"My m nMlustrial .•on.nnnnli..s. hut the leMons themselves
ure ott..n .,t a seri.M.s onler. Sine,- ah.lnnn'nal injuries are
"<-«"ly aluays ,lu.- to the loealise.l in-pa. I nt vi.,l..n,e an.l
i'"t to ueneral eontusion. so the |,.,ions pro.lue.-.l an- loeal
h'sions. an.l the nervous system as a rule is spar.'.l henee
one pv,. teature eharaet.'ristie o| thos,. wl„, sutler from the
secpnla' is their immunity from traumatic neurasthenia.

hi the foMowiniJ seetions. the etTeets of injuries to the
:'''<l"""nai uall are eonsi,h-re,l hrst. in.livi.lual vise,-ra, hein-
dealt with sul)se(|uentlv. ^

Tf,r Ahh„r,n„l IIV///:.- The ant.'Hor sulh-rs more fre.,uenllv
than the posterior aiMJominal wall, ventral hernia' resultin"-'
iroin stal) ^voun(l:; or fojlowin.. exph.ratorv ii.eisi<.ns. while
<l>i-eet rui)ture of one of the al..lominal muscles is verv rarelv
rosponsihh.. The muscle which is most lial.h- to rupt.nv is
the rectus ahdominis I.elow the uml.ilicus. and the fact of its
rupture may he taken as iialici.tin- that the hlow was not
idtoj/ether unexpected, tin- muscle in fact hv its viol.'i.t con-
traction havinjr hroken the fore- of the impact and thcrehy
sliiel(h-d suiijaeent viscera from injury. In opcraii.a.s upon
ventral herniie which arise in this manner, it is often found that
only the deeju'r l.-v.-s of the ah.h.minal wall have <riven way
while the more vvperticial layers are still intact.' .McCJav'iii
has re))orte(l a case in „hich rupture of tlu- rectus took place
on the left si.le. a ventral hernia followed, ami at operation
intestine was found lying JK-tween the ruptured muscle and
its anterior sheatli.

Retroperitoneal <ysts. apart from tlios. in comiection with
the hvei and spleen, have heeii observed, in which trauma was
held to l)e rcsponsihle : most of these have heeii l)Iood.cvsts.
They prohal.ly arise l,y progressive enlargement of luuiua-
tomata.

M

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'•'"'•: \( I TK \i!i)()Mi:\

«,vn,,,i.,„H ,„■,. ,i,„„. ,1,,,. ,„ i„„.,i,.„., , r ,1, ,1 ""•'"* '

i!;;;"-" "7"- ■■ ;:::;. :;;K,;!;r;:":;;'^

;i;LJ!::,,.t.:;r:,;:.r::i7''-';;'"''':'

^;£.:p:p::*;:rr;;;;;::;,Ti;;;:-t::i:|;;;:::,::

:;i ■■■■'/ xl^'™'^ i/L!:l'';;.:;'i ;::;::;; ^:^

:;r":v™, ':;^!^:r:r'-'r■"■''■-^'''■'•'■'
■ I '.,;'; '•'""','■"■"" "■"■• ■"■'■ '■"•■■■'"■■ -I ''™-

tiK- t.irmci- nn,l ,„„t,i,i,,„, ,,, ,|„. , „ ,, ' .'"> ['■"""

«- f«n„„. I,,,,,,,,-. ™,r,.,.,.,i , ,, ,.,,. ,i ';,!;'" , •^':"""'

.;™-.,,,,,... . :-:-■^,-;::;-■-;»l,.™;_-
-":::::;;:;::v;:;;t:r;;;;;;;;r::'r-;■:,:;:;■"f"'

al.s...ss may .xt,.,,.! till it n.u.lu.s ,|„. s„,.fa. | . it i ,""

%

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THE .\( ITE Aimo.MlOX

fxistiug gastric ulcers or for the forruiUioii of new ones. I)ut
it seems more than ])r()I)ah!e that if injury plays any part at
all it can l)e only an exceedingly small one.

Intraperitoneal adhesions arc not likely to Ite formed nierelv
as the result of ha'morrhage. sijice extravasated Idood is
ai)s(>rl)e(l. an<l appears to have no other etTect than the produc-
tion of temporary agglutination of peritoneal surfaces : hut
adhesions are undoubtedly formed whenever denudation of
))erit()neum occurs as the result of injury, and their action is
protective in that they strengthen an olherMi ;e weak sj)ot
in the visceral wall. JJut. llu'ir object once attained, they
cease to be of value and henceforth become a source of dan<'er,
since they may under suital)le conditions be directly causative
of acute intestinal o}»struction. Cases of intestinal ol)structioii
are common in which peritoneal adhesions have been respon-
sible, such adhi'sions having formed aft. i abdominal injuries
or their operative tn atment ; l)ut it must be confessed that in
most of these cases the adhesions Mere due to ojK'ration and
not to the injury itself.

Simple stricture of the small intestine has been known to
follow injury, but here again o])eration plays the greater part,
since the stricture most frequently occurs at the site of suture of
a perforation or at the line of an axial anastomosis, but it is
possible that cicatrisation of a contused wound of the bowel
may itself be responsible for stenosis.

Traumatic appendicitis is recognised by some, and if cases
of recurrent attacks of pain in the right iliac fossa attril)ute(l
to injury may be regarded as due to that injury, then chronic
a])pen(licitis nuist be iiu-ludcd among the setiuela' of abdominal
trauma.

The duodenum, owing to its fixed position, is particularly
liable to contusion, though its depth from the surface renders
it less likely to sufT(>r in stab wounds. < )ne result of its rupture
is the escape of bile and jiancreatic juice into the retroperitoneal
tissues Avith consequent abscess formation, and here again
fistula> may ensue, or duodenal stenosis and gastric dilatation
follow. If the peritoneal surface of the duodenum be damaged
and the case does not immediately prove fatal, the formatLn
of a subphrenic abscess is e.vceedinglv likelv.

The M( St iitenj.— The sequehe of mesenteric injuries are

f : '^sm

AFTKH-KFFKCTS OF AHDdMIX.M. INJIMIKs

tew and rare. Laccrati..!) „f tlu" iiuscUcrv inav Ix- f..ll„w,.<l l.v
cicatrwation an.l c'.)Msi.,,uoMtly l.v kinking' "..f tlu- h.nvd"-
.U'structum (,f its ,„.rit..n..»,„ ,..,y .„urt the for.nati.m of
adliesioiiM, and oxtravasatio,, .,f I.Io.hI lu'twc.-M its lavcrs ,nav
ultimately form ,.iu' variety ..f the i.i..s,.„t,.ric <vst ' |{„t t'u-
most important of all the lesions. I,v virtn.. of "its af.-ndant
nsks to lite. IS mes..nterif perforation. Perforations „f the
mesentery due to injury are a perpetual menace, inasniueli as

causoil Intotiiiiil Ul)stniLtioii: "m. .mmkh

Museiiiii.

•'ill, St. Tliuma>'.-i Uosjiitii

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at any moment they may snare and incarcerate a wanderin.'
cod of bowel and initiate acute intestinal obstruction

Thf Lirer. Pancrea,. and -Sy.r». - I'erhaps the most
cliaracteristic sequ(>la of an abdominal injurv affect in<r the
solid viscera is the formation of cysts ; if infection .Krurs
abscesses result, but. except in the case of the liver steri'<>
cysts are far more common. .\s in tlu- case ,,f the lu.llow
viscera, adhesions are more often <lue to the operation than to
the lesion which prompted it. particularlv as operations for
Iho rupture of .s„lid viscera so often entail the introductien
ct gauze packing into the abdomen.

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THK AciTi-: AHDO.MHX

i.^Io > ot alMl.„„,n;.l .ra.una : al ..,M.,alio„ a ni,,lu>v of iU, livrr „ i.
I" <..M- ^ as l.H. tar a.lvann,! to aa>,nl ot aiiv lio,,.. a.,.l ih.. „ati..„t

:l:;i;„.;i,;'i;;';:;r ^^•-•'•'■■'-'-''■'■-va..i,..ov..nJ....,on.i,L.',;::z

IVrtoratit.g w.nut.ls „f tl,,. liv.r may h.u\ f. Itcpatic al.scc..
will ,> sul,,,|„v„ic abscess ...•casi.mally toll„Hs ,„,.tu.vs. thou-'lt'
ran-ly iii ..iico„,,,|i,.at(.,l k.siott.s. Wuutt.l. of the ^'UI-hlmhUT
s...,H-tt.m.s result it. biliary fishila and w.u.uls „f the .lucts „i
stnctun. with obstructive jaun.lic... ()u ,h,. wh,.lc. the sc'iudu
ot mjiirics to the liver are excci-dirifrly rare.

The pancn-as suffers i.u.re fre.,u,:,;tly a.i.l ,,resei,ts a greater
yaru.ty o iesiot.s ; ai.mt.jr the se.,u,.la. tt.ay be f..u..,l lesions m
t u. glatt.l ttself as well as lesions in the t.eighbouring tissues
Although ,t may seem incre.lible. prolaps,- of the patu-reas
through an abdominal wom.d has b,.,.n observed. Intla.mn,.,
tory sequela, have been tvconle.l by variou. writers ; thus
tiVA an.i Ha.isematui describe cases of necrosis of the pan.Teas
ollowtng u.jury. wl.ile Kollestoti reports a case of abso<.ss of
tlie Jiead of the oraaii ■ —

A Nvoman ot .V. r,.,.,.ivc.l a l.low on ,|,.. alMlo,,.,.,. which was 1 wcl

at once by pam.an.l, he next .lay by severe vo„Mtm..n,nsti,,al ion ,

.apse s.nu.latn,. intestinal obstruction. The vT^nitin J.! i u '
;H.l c.,„st,pal,ou «ave phuM. to .lianluea. though this was,,,,, se -,,
U.. months alter ti... injnry an abs.vss ,:ev..h.p...l i,, ,],, ri^l t bv,o'
.l."ndrnnn a,..! a tortni,.!,, h,,... ,b.. p,„,.„t lli...!. M t e ,.e n J

^rX:":uZf:-::zr • ^-"'--':'^:""

^^ Cysts of the pancreas due to i.tjury bave l,een classifi(>,l a.
true and "false." the latt<.r arising by ch.s.tre of the

oramen ot Ujnslow at.d cystic .lilatation .,f the lesser sac a.ul
the former by .lilatation of the lesser ducts behind an obstruc-
tion of the ma.n duct or of one of its large l,ranc.hes a.ul brought
about ,.,ther by direct injury to the ,luct or its ste.iosis bv
mvo vement in scar ti.ssue. Pancreatic fistula is caused
by the incston of a true cyst or of a pancreatic abscess an.l
rarely by retroperitoneal rupture of the duodenum False
cysts Of pseudo-cysts of the pancreas are due to the effusion

;;:;!::' trr;;, ; '—-"■■ '.^.i

•"■™'"» of rtu'hHl, ,:,;,;;:'": ""^ '"■■"■■ ' -i-

<*ii .fiiiic |;( ic)(u I ^.,,,

'w-n.y y..a,s [,.,o,v h' ha.l lu,U , ,, . T""'' '^'"■" ""^ "'^"

'■"'-'"■<l '..V a ran uKain., -. « ,'"'"'" ■""' '"■•" -v..„.lv

""•'""-""1... MH.iu ;' ■' '^^^^^^

J'i^'-y ol s,,.ai.. ,l,uin„ , : ' •" ""■ .^V""""- ■'••"■'-• wa. also ,,

v-" •"..! pain ,n .1... ';,l;;.' .:;;;:■' "•""'" ";'" >■-- '"■f"- n.^
*^'';;'-" '7--- iM.a;i,;!:::;r;:;';;;;,:''''" '">--•-

wiH-n. u::,.;\;';;\;';:;,^/;;:;';^^ -r 1..,,, „. ,1 „i,,,„,„„.

fn'oly. l.u< p„|sa,i.,n ,...aM..l , ^ ;:. ''IH^' ^ J": '"-'• " Pnlsa,..!
w.'ll-„,ark,.,l (l.i.M„a,io„ , , ^ "" "'" """''■ ■'''•■"■ was

«a. ,.un,.„.n.,l wh. ;,:'', ^J:'''''' ^^ ->- •'"'i.".... Ti... ..vl,

"ff- Tlu. I.un..,u,-,.su,.„„,, , ; ; n; '!' '"""" """^ '''-->'

1<-I><>it stal.Ml : •■ T'. Ih.i.l , , I • """* ""^ <-^atiuM...l. an.l ||„.

.•..^^«uia...s .,„ ,, „„.""; .';;'•"',';;:-' - ••■■• ^'..'..ly aikah.... J,.;

de,H,si, with I.!, ..l...llsan;u;aM;.i;;„,uu""'" '"■ ''■'■""•""^= '^''^''^

seen. J.is.in,., ,„„;•..„„.,., ,1 ' ' " 'V"'" ' '"' '"" '"'" «as ii,st

'i'ho .-.vs, was now „,,.,„ ' - ; "■;' " J-" .'"' '•''^'"«-l '"> P-siUon.
thoroujrh ini^ation , .. •:.'"'• " .""'■-'v- dui.l ..,..,„.,, ^ aft..,-

:ati(.ii ii was iliaiii.M' AIum

n.s," tWK,., whil,. ih,. ,lis,-),an.,. I, ,, ' "l";'"""i Hm- t.nip.Talnn

"■''" 'l- Th.. ,a ,i,l... ; „' "•■';■-'•"■■'' "'""I'—Mn.

^^•••■■ml n.Kli.Mi.Ml 1,> .lis,.!,;,,.-. , ' "r '• ""'■'• "<'"-'liv... TIh

-11.* I * ■•■"■•iiimiiii'M

;> '".. w..ak ,.. work. ,„ j,.„ ,„. „.,.^

-'.■".lin« .ransvnsHv 'ou:''';;;' """-'"•' Z'" '"■" " 'in,, ii.as.

""'''i'i''"l .VKion.was a I ^ .v n""""-, ::'"'" '"■'""• "' '1'"

l"'lsa.in.. Th.,..„.p,,.,, ;\;.;; ,;";'''''^' 'l""-". p.M-..us.ion an.l

''■'"■ "I'l w..un.l was ,..o,„. .1 :. ""'\ ""• '"'""'^ "••'•■<' ■•.■^..larU.

I'nrk „.o„. .In. s„,,a,. ";.;". ;\',^r' '"-"';7'-l a> a .1,,.,,, ;.,

<-"-^<' -s .^.un.u:;,* ^^;:; :;:';::• -'■'■•7-''''<^-'y^ •>.--

•••'P<-l-an.lwlu.n,ln.,,uU..,,Ue .!;.;„. ;:r"''"^^^^^^^ "^ """"<■=-
A.A. iLH.iu "<-iH-a]lLc.smu»i,aaaini..si,.l,;s(.il.

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Wiu'ii first s( . ill tonsuitiitioii the n'M-iiiblancc of tlic cyst
t(t an aneurysm of the alxloininal aorta was very closi'. flu-
stoiiiacli appeared to lie disjilaeed downwards' and 'lie cyst
came forward to tlie abdominal wall, to which it appeaieil
• iosely applied.

injuries to the spleen are more comuKm in those countries
v.'here malaria is prevalent. Small lacerations heal, and },Mve
rise to no sym])toms other than such as may lie accounted for
by the jiresence of adhesions. )iut if infection occurs, as is more
likely to happen in stab wounds, then an ab.seess may result.
Trauma has long been held responsible for certain cysts of
the spleen, and not without cause, since tlu-re is abuiulaiit
evidence tu sup|)ort the contention.

It. I'dwIciV series I iliere weic no less than five ea^^es id splenic evst
111 whicli a (leiiiiite injury lia<l been received less tlian (.lie year
previously. Lejais nienlions a ••a>e in wliicli a woinaii was seized
witli severe |iaiii in the epigastrium, witli diarih.ea and vomit iiiK.
ihive years alter an accident in wliicii she was injined ; a cyst was
toiiiid in tlie siilenic region coiitaininu \\ lilies ot liiiid ; tlie wallof
tile cyst was roiij;li and (il.iinous and suj;j:ested a ha-matoma ot loiijr
standing. Ileinlanx also records the case ot a woman, a;;ed 27, who
developed a splenic cyst ei>;lil years alti'r an iiijniy, anil here ajiai'n the
cyst liad evidently arisen l.y projf.vssive enlaiKfinent of a hieiiiatonia.

While the majority of these cysts thus belong to the category
of blood-cysts, tlio view is hekl by some that certain of the
serous cys' may also lie of trcumatic origin by inclusion of
j)critoneum during the healing of splenic lacerations.

The Kidncy.o, Ureters, and Bl.idder. —Though the onset of
symptoms of nejjhropto.sis is sometinu's attributed to injury,
this tactor cannot be held responsible for tlie condition. It is
more tlian probable that in all sucli citses the condition lias been
latent, and Jias only been brought into prominence by the
general functional disturbance and the possible medical
c.\amination following the injury. Injury is also said to play
some part in the production of chronic nephritis, but here
again sufficient evidence is lacking to prove the assertion.
Stab wounds of the loin, if penetrating the kidney, often lead
to urinary fistuhv, partly owing to the introduction of septic
organisms from without and partly to the decomposition of
cxtrava-;ated urine. Urinary fistula' may also result from stab
' "Annals of Surgery," l'Jl,'J.

i

iiii

AFTI:R-KF Fi;( Ts OF AliDO.MIXAL IN.IIHIKS

s:!

wou.i.ls ..t ll,,. luvt.Ts „r l.la-l.l.T .,.■ frnm fMiajHTitniuMl
ru|.tuiv..t th«. l.la.ld.r «itli iiriiiarv ..xtnivas;iti..ii ; or. aiiain.
they may tollow ..imthI iniis t,.r ihr «x|.omiiv ..f Mipnir,..!
IvKln.-ys. In all cases in wliidi iviial liMiila^ tail f,, |„.a| ,„„|,.r
treatment, nephrectomy is the only .ivailal.le cour..' to pursue.
Stal) wounds of the ureters are rare, hut ((.ntiisions are less ran- ;
liei.ce numherless e.vamplcs of their se.picla' are on r.voni ami
m these, in nearly all cases, the uret<.r has un.l.'rirone cicalrisa-
tion at the point ot injury and hydronephrosis has resu ted.
While true hydn.nephrosis nay l.c formed in this manner,
the so-called •• traumatic hy(lronei)hro.is ■ is forme.l (,uite
•Idlerently ; this variety of cyst indeed is not a hydronephn.sis
at all. but a cyst of extravasation, an enca|)sida"ted collection
of e.xtravasated urine arising months, or even years, after an
injury in which the kidiu'y underwent i)artiai rupture. In
tiK'se cy.sts the kidney may sometiiiU's he felt, of normal si/.e
iind not apparently di, leased. Kxami)les may he .pioted from
the St. Thomas's Hosjtital Hej)orts : —

A iiiaii wiis iulmitt.Ml liuvinj; Itccn mil ov.i mi .liih 2s ISMC. II.'
siisiaiMcl liariuiv.l .il,s im.l alHli.niinal iiiiuiics, ij,,. ■,.x;.,."i „„tiii.-nl
\%lnch was iioi ..vid.iil. l.ul iic, si;;„s ..t iriial injinv wciv ,.l,s,., v.l II,.

was rcailniiltcil ,,M .S.ph.n.l.cr :i will, ail .•iH.nii..u> tiiiiil ^^^,.||irl.^,„•,•M|,y-
iiii; the \'.-U M.lc ol 111,. alHl,„ii,.|i aii,l ,.M,.|i,li,ij.- Im^vuimI i h.. imhI.II.. line

ill.' ..veilyiiii. .km was iv,l, sm 1,. sliii,i„ir ,„„l ,,.„„.. \, „,„.,.,i,j„„

«, l.inls „| iirineiis !lui,l weiv williiliaw ii ; i li,. lo,lii,.v aii,l iiieli.r
aiMieaicl iiormal. -ll,,. i,ati..|ii ma,!,, a -(...,1 iv,,,v,.i\ .

Aii„ili.Tiiii,.,-,.siiiin;,.;,s,.wa.llia; olaiiia.i.a-,..l:.>4.wli,.wasa,liiiiil..,l
a^auii...,'iil.-a„.|iiid,.rlh,.,.an...l l»i-. II. !'. llawkinsoi, \„v,.n.l„T •'!
lN!»!t. II,. slau.,l Ihat he tiisl l,.li ill ..„ ,1„. Lsih. l„.l ,,aii. in 1 1,., lelt
si.l,., aii.l was uiial.lc to o„ „ii ,luly. .\,..m n,..iiiiiij: |„. was wois,. 1, „l
an attack ,.l v,.i„ii iiiu. ami tli.. i.aiu was i,,,,,-,. s,.v,.ie. Tli,. alMl.iii,,-!!
was much ,.iilaij;e(l. ..spc-ially across the uml.ili,.al i,-ioii ■ il'i,. w-.s

11,1 iiioveiiieiit oil rcs|,iiation in th,. !ow,t and v,.|v little in Ih

upp,.r

pail. (In peirus>i,.n an aiva of .InliU'ss was tonn,i all over. ,.x,...piin.'
tor a.sn. II spare in tli,. upp,.,- pari nn.ler the ii«ht costal maiM;in (lv,.r
I he wh,..e ot this area 1 h,.ie was a tlni,l ihnll. but the dnln..ss ,li,l n„t
change with alteration in t h.. i.osiiion of the i.ati,.nt. 'rii,.ie was much
tenderness on th,. light si,le. Th,. g,.|i,.,al ctlVct was that ,.r a lar.M-
|latt,.ne,l ,.ncyst,.,l ..ollectioii of Hni.i, and it was not possil.le with this
history to give an ,.piiii,.n as to iis nature. Alter ihe operation, when
he ha,l r,.cov,.iv,l trom I he levil l(.:{(i , ail,l upset of t he acut,. ,.on,lil i,..,
lie r<.m.'ml.,.ied tiiat he had l.e,.n ki.'k,.,! in tli,. ahdoiiM-n soin,. iw,.|v,.
years heloie ; the injury was sever,., tnil he coul.l not sav aiivthin.'
»l>out the ••.mdilion of the urim- a* that liac. On op,.ning the i.,.ri"
tomnun in this cuse, the .same evening, a hiniiiu siutae.. haviicj the

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TIIH ACITK AHDOMKX

' '*''^ '"'""' "'•" ""■ I'''I><'M Ol Mill.) «as ,..ll0IMTJI..Mr.l ...... I

U.liH.v. wliiUl 11... s|,!..,.n .-..iil.l II. . I 1... |,.|| Til., snr.ll i,,.,. ,

-r'""' ;•• ""■ ■*«'"■ -"i ' ■.•^-.■....u,« „ ..;.i:.: ■;■ ! ::;,:;;:

•— • .iowMw.nl. ,...,„■ ,1... M.Hl.ll.. |„... ,., ,„.. Iv 1.., ,|J1 •

;;'-'-"-. 1..S , .,...,..„« was su.ur...l an.l ,1... ......li,,, inns.,., ."

m.l. ..V..,. H p„„s w..,.. ,..,„.. V...1. Tl... wall ..I ,i,:. ..av . , 1.

an. ..v..,,vwl,..„. a.lh..,...,,. s,. ,l.a, .... a.,...,.„t wa- ,..a.l.. ... .v . ■ .

• a,«.. .l,an, ,... ,,.!,.. wa. ,um.,L.,1. Tl... Ih.i.l ... ,.,ai,.,..l .....a .- ,.,l ;

"11.. |.„s. ..,„ ,„. .,,vs,als. Tl... ki.l,...y was ,..„ „.|,. Th- si,.,.s I . , ,

.- I...' s....... w....ks a...... ho I..I. ,1... l.„.,,i,a|. I„„ i,„ ,,„i,.. ,,„...

aiKl ivs„„„.,i duly as a |...li<.,.„iai.. i"'<>\n.(i

l.j a.u.tl.,., .-as.. II ,„s.. „t ,.v..,.ts was „.,...l, „„„,. lapi.i. V ,.l,.,.L-

aK...l U. was a.lin.tt..,l .,i. Ma.rl. 8 a,..l I..., .,„ Ap.il -i l<,„i '

I'iV.. w,...ks l„.|.„v a.l.i.issi.,,, |„. ,|j,,,„,, ,,„,i ,,.|| , ,
^t..k.,.. I..S „«|., S..I... Tl.,s i,.,j,„.v was t..li..w..,l ..V S..V,.,-.. a, 1,. '

I. as ...1 ,,„. a I,.,,,,,.,.,. ,„.,„,^ „.j, ,.„„, ,,,. ,,^,,j ; ' ; J

ffl W..1I ai.,1 r..s„„u..l w..rk attain. On .1,,. .hir.l ,lav aft.-, ...i 1
..... <1... ,,a„.s ,v..,.,.....,l au.l w..,v „.,.,.h „..„... s..v..,v to:- UaLcZ
tl...|. .l.sa|.p..a>,..l. Tl...,v ha.l I„.,.„ „., |,,.,„a...,ia an.l h.l -h . , h,
wa^.,,..l..w..il..,„, asw..|||,..ha.lapp..a„..lh.,h..sul '

•a.) was .l,.|| ,.,. p..,...,.,ss...... ,1... .l,.l,...ss l.,.i,.. ....,„ !,.,..„.'s w h

'"• -v..; a... ..x,..,„l„„ as fa,- as ,1,.. ,.,...,i,i..,.s „.,vunls ,h,. .i . .

!,"■• " -l"l "'" .l.a,,... w,lh a!..Mati„.. ..I ,1... p.,siii.„. .., ,i., „, ',

il...,v was w..|l..na,k,..l .l,„.tua.i...i i.i this ur..a. Th.. l.-l, s. - '
"">"';'.'•,'"" "V"'- tl- 1..W..,- part, n..a.- th.. «,„i„. tl...... wa • |. ut

. s. sw„l .... au.l v,.,y pa...f..l „n p,...ss,„,.. Th. u.i,,.. was st^ , , y
alkahi.... l.,.t ,„ „th..,- .•..sp....,s th..,-.. was ,.„.hi,.jr abn.Mmal lu u . o,.
."xa....„a.,.„.. .)„ Ma,-..h !. a h.n.l.a,- i,M.isi„„ was ma.l.. -m I t o rv
.■miH....l ... alu„.t 4 pu.ts .,f ,.,.i,..„„ „,„., on the ^^ ^.C s- u. '^

'K .. It. ll„s was ,vj:anl,.,l as th.> sit., of a i-......,,. nipt,.,,. ?),■..;„.,„..

was ...„ployo,l a.i.l the i„a„ refoveiod. "'l>t>'» . J)iai.ias..

If the- l.i.tory of a renal injury i.s sup,,rossc.(l by tho patic-.it
as It was 1,1 another case, tlic collection of tiuij niaV be mistake.^
tor an ovarian cyst.

\n tiumanied w...na... a.-.l :U. was a.bnitted on October If. I'M,!,
hhe hud boeu treated m another liospital lor the re.ult. oi a .'^S!:

AKTKH-KFFKCTS OF ntDominm. ixjccks h.t

M-i.lrni in ,\|Mil. .huinu whirl, >|,.. h,,.l i ,

I Mill OV.I l,\ ,1 \.||, 1,1

''"'^ '••'"• "-I -ay ..iivlliiiij; Hi ,, <| , , „ '""^ " I-

'^""!*>. '•■••- "M--'' ". A,.ni. .... ,ii., ,...::'';,:'>■''. ■'•■

<• I'lll.llllxir.l Ihal {ilioill it

u.Tk allrnvani. sh.. h,,,l .■, (v iri,.,..,, , "" "lai „ ., „

;;'* ':;■'•■■ ' -•i'-n::::;::;/;,::!';:::;;,:;:^:';,;:;;::

<"..■. llMsryst «.,n,M.„,..l,„H|.ln,i,i..,l,|„„„„|,,|,..|., , , 7

:r':t..,r - "•■- •• •-^;-';;i:^.'::;;:::.:;:;..:;^';r

Th.-sc. rases show flu- ..o.-rssity for o,.,.„sio,i;il ,.x„ni,K,t i.ms
-•'tt''rronl,.s,ons,,t fl,H<i.lnry n.^M.in. altlion.l, ,,,. si..n of .,.,,,, I

vlwiMK HttcT a ruptumi ki-Lu-y i.wli.at...! hv tlu- „s,.al -i.Ms ,.o
tun.our ,.ouM 1„. fonn.l fl.r.... w.vks aff.rwanls. at tlir U,nr of
. .sH.arM... I>ut a foHni.ht la,.,- |„. was a,l,ni„...| ,o anotlM...
I.osj.ifal for a .yst which r*-(iuire.l .mcratioi,

till

i i

111

TAUT II

PKKITOXITIS, :HR)K ATlONs Axf) oTHKH I.KSS

ru.MMOX CAISKS OK THK \( (TK AI5|)(>.MK\

IXMITOXITFS.

'I'ln^: ariilc ii.(lan.inafi<.n ..f ll... iH.fitnMcu.n wlii.h ... |V,..
qiirnlly fon„s a j.arf „f Uw- acuf.. alMlu,,,,.,, var; .s «n-aflv
"•■'•-n I..U fo th,. .•■•ns,. „„ wind, i, .Irpcnls. the- nn.i.li. v..f iN
s|m.a,l. an.l thv ,,ar. wImt,- it has its ori^nn. It also" varirs
mc.nln.K' <-> tlu" miml,..,- a,„l vi,„|,.,„.,. of tl„. p.uti.ular
..r«ar.,sms uhicl, hav fnuM.I thHr way i„t.. it, tia- now,.,. „f
Hl.sori.tion „f tlic in-nUmrnm. and 1).- ivsista.w,- ,.f fl,,.
individual.

r-i this s,.,.ti..u it is not n.Tcssary to dn,.|| v.-rv much
upon the symptoms of an inlianunation wiii.l, has to 1„.
(HMisidm-d in ain.ost vsny part of our s,,I.j,.H. wlu-tlar
It follows an injury, inti-sti- d p.Tforation. app,.n<li.v p.-r-
foratnm (Im^. !.). intc.iinal ol.st.urtion. or invasion fn
seme asccrtanu.d external source such as that l.v the Fd
lopian tubes. Here I only wish to mention liu- .,.„,,al
syn.]>t<.ms which are ni, t with in i>eritonitis and rrte. to
those varieties i„ which no ^moss cause can he foun.l. 1,ut
Ml which then- is an act., bacterial invasion l.v some
organism winch has probably obtained ...itrance through the
blood-stream.

The- patient complains of pain in th,- ,d.don.,.M. mostiv in
tlie umbilical ivuion, becomes feverish, complains of ..hiiliness
and probably v.miits. The temperatur,> rises and the .nils,"
...oreases „i frequency. The j.osition soon assumed bv the
l)atient who has gone to bed. feeling verv ill. is a verv charac
tenstic one. for he li.-s on his back with arms thrown above-
the head and the thighs fk-xed on the abdomen. When
exammed a few hours afterwards there is m.icJi tonderness

Wi

I'KHITOXITIS

M.m..tn.H-H a.n„unti,.K t<, l..v,M.n,.Hflu.,i„. ,,,„., i ,|K. „)„,, ,,„,,,.

.s an ...flammafion whi-li i> .vhM.li.iu. Th. ,■ ,,|,Lm nf

P'UM may 1... I,.ss i„M.,out. ul,i|., it, ,.,.,, ..v.,i,v i< .,f,..„

."«luat...| hy tl... a.m.unt of ....In..,.. ,.„,| ,.„.„ v.M.-.tt,..,, nf

Ik .km win.. h ha. -"'h-l fmm ,|,.. ,,,,.,i,,.,,..„, ,,,,;,,, ,,^^^...

;''''>'''l/'>-;'lm.Manv>,<.H,a,,.hlH.nM>Mill,.....a.i.nalv,.,n,.m..

Il.m. .s His., v^n.h.y of ,1... a..<lo,MiMal rnn.-U . ■ ,|,i , , ..

localiM'd at fust. I»iit
may hccninc jimcral.
Tlx- i-.icv is (lii-linl.
there is a furred toiiittie,
uikI usually ((mstipatioii.
Percussion may yield
hen' ii<»le iutorMiafiuu
'Mitil there is s(,m,.
exudation of liiiid ,,r of
lyiuph. Ill the former
instance it may he free
in the juritoiu-al civity
and vary with the
patient's position, or it
May be patchy or
localised to one spot,
as ill the latter. The
J)atient will often l,e
restless, and call out
Ol- <>nr,m when the
|>ain

■■ !».~l'ill |)ri>tnillili- tllliitl;;li ;l Jlfl Inl:,

tioii '■!' thi' .\|ii)cM,iix ,111(1 (•.iiisii,:,' l',.|i
tomtis: ,s«t. 'lliMiiuis's H,,-,.it,il .Musciiin
N'C iiisd Sui-',';tMl llisiM-,- ,,f ih.> .\iip(.i,

«ll\. •-'11(1 ,m1. "

j)aroxysms
become severe.

Later the expression
of his face cha.iges. he is listless, dark lines appear belo.v
the eyes, which appear to have sunken, whilst the cheeks
are hollow. The lips lu-conu- drv. and the ton-rue dr\-
brown and c<, tt-d. The breatii is ofTensive. ElVortlcss
vomitmg continues and is now copious, whilst the ejected
fluid becomes brown-col ured. bad smelling, and even feculct
Kxamuiation of the abdomen .shows an amount of dis-
tension which is apparently increasing, and the wall of the

abdomen is moving k-ss than

ever.

Tliei

•re

however, no

H8

Till-; .\« I IK AHDo.MKX

llm

» n>f. >K to ... ...,.,. ami fl,.. „„.f.,... |o.,k, Mnnoll, : palnati.,,.

Hpmn.nlan.l.nn.l. , •....,..., I,, V, I,,., ,a,i,.„,. |. i. .',,1 .i.i.l

"""">■ '•'-""""• •"'< i" tl... (Ia„ks ,Im,v ,„av I ,ln..>. whi,.,,'

.■an >...MHmM.s I... ,,,.,....1 a.,..,, ,!„. ...i.l.ll.. Ii,.,. al.uv.. ,|.,.

P"l»«-; 'MI.K,>.,.al!,n.|,hnllmayl.....|,M.,.,| TI... f,.,,.,,..,,,.

••nv .> ruH.]. nn, .......ssarily very l,i«h. I.„- it ,nav 1... nonnai

or M.lmon.Ml. ..v.„ „Im„ ,1,,. in(i,n„,n;,tin„ is i,, ,|,, .....s,"

H.-v,.n. ty,,.. w,tl, a u.-mial .JiUusiuu ,.f pus. Svvh a low
<«;".I>.Ta.ur.. .i,h a .api.l ,...U.. j. „f ,,,,, ,,.,,„„, ,.„^ ^,^^;
"..; n.n^f,pat,..,. >.s pn.l.al.ly r..!i..v...| |,y an ..n.-.na. ami ,1,.
I'|'>'|-"f pa>M.. llatns wifhon. any .lifli.nily „„.il ,1,,. .Ii>(,.,„i,„.
;•» t ... .nf,..t.m. .s .].... to patalvM. of ,1... l,o„,.| wall .a,,...!

I'.v 111.- -...Mial poivmin^. w|,i,.|, |,a, Mip.-fv..tu..|

IMS alu,,ys of ha.l im,.o,, i„ a ..as,, of p..,itonitis fo (i„,| ,|,at

H pa.i..„t has lo., all p.i... ami has ..o,,,,,,,.,,,.,.,! ,o hi<...o„«h

W.th fh.-s.. symptoms .luT.. may I,, a ..|..aMu.>s of iMt..||,.,.t

h .h .hs,„.s..s ,1... n.al slat., of ,h.. ,„a„ fnm, his tH.-mls.

MlN,st lh,.tn..p,..Mt p,,!sHH.,.,,,„i„.al,,,ostor,,„i,,.i,,,,,,,,, ,i,,,,.

warns tl,.. m..,|,.al att.n.la.,1 iha, ,h.. ,.|a,„mv. ...oist ha,„l

uh...|, 1:,. took on .■nt...inK tlu- room was in,h.,.,ra tru.- «itn..ss
<> <lH' palMt.ts Stat., as alr.a.ly i,uli,.at...l l,v th,. nnrs.. in
cliarg... • '

A ivtun, of tl... r..stl..ss..,.ss an.l siyhinj. .-..spiration aiv also
na.l symptoms.

<i:.i.;ma of flu. al,.l„min;,l wall n>ay i-alicat,. a lo,.alis,.,l
c'ollorfon of ,>„s or an ...xtravasation „f ,.,.,.. into th.. ,nnl,.r-
yM..e atva of pc-nton..,,,,, : hut th....- is anoth... torn, of n.,l..n,a
<.t th.. ahdonnnal ,,ari..l,.s to whi.l, I .hvw attention so.n..
^•ar. aK.. |J,rs may h.. s...-,, wh.-n th.. p-mtal peritonitis
s ^( r\ a.-nt... It a.coM.i)aiii..s an intlammation <.f the .dlular
tissu... an.l ,s ..ansccl l.y an .■.xu.lati..n whi.h has pass..,] intoth..
.sul,p..nt..n.al ....|lular tiss,,,- an.l ,.on,.. out along th., inguil.'u
«anals : ,t may spr.-a.l into tl... Mrotum. an.l lat..rally ^.war.h,
t ... ant..nor superior spin.^s. I,..t n..f into th,. thighs h.-vo,,,! the
att;u.hm..nl of th,- .l..,.,„.r lay..r of tl... s.,p..rfiei, | faseia

It m..y be ^tate<l at .mee that a lo.alise.l inflammation of
nu. p.r,t.m,.un, is not always a .lang,.rous thing, an.l tev
.11., Om.nal operatna.s which a... earrie.l o„t mul^r the most
p..rfeet asc-ptie eomlilions are uithout a limit..,! perit.,n..al
r..a.t„.n wh„l. amotuits to an inHammation. In the same

■i 1
j J

I'KIMTOMTIS ^„

«h. •!. that ,„•«„„ I,,.. ,., ,h, .,,,„,„, p„,i,.,„.,„„

Most at.a.ks of iH.nt.milis ..„„ |,.. ,,,,,,.,, ,,_.„,„. ,.„,,,, ,

. Ka„,s„, or to so,,,,. .iHinit.. Ui.., I,,,, ,, „,,,. ahvav. v.

tiMT,. ar,. so,,,,, ,.a...> i„ „hi,,| „,^,,,„„„ j, ,|,.,„„.;,.,| „„

™,Ma,,o.. ,y,I...W,n^^^

"..... .''''?''' ''"' ''*••■" '"•••♦"">■ -"nli".l. Mr,., tin.

I th,-,., ;,iii,,!,r j|,;,f ,,|M.ra»io„
It i»il,ilik..|yflial a tliii.l ii,||a,i,,„a.

syitiptntiis „iay h,. so scv,,-.
i>'|K.rt..ri„f.|, a, III rightly so
forv
111

.rv ,.xu.lah. wonl.l .vinai,, s„.ri|,. f,, ,„a,.v I ,s. (......aiio,,

avsav,.f|„. I,,.. „(.;„.,, ati..„t.a,Mlshoui.l„ot I,.- oHav.-.l.

• iiiaii ai;i.il Jj.

^h,- st„i,.,l ll.at ,1,,. ha.I ,1.., I.,.,.n l....|„,^ ,u\\ I..
Imtii vomili,in ill i,it..,vals. will, a slin)

laciiilh ; III,.,,. |,,„|
I'imit: pain .11 III), ill.,!. .III.. II.

:.i'::'";-:Hr'; ;;:;; I::;' V" ;'■■■ ''"- •■"" ■"■■ ''■■ '■"'"".>-'■

r... ..a.. *; . " '•'"'> '■""^""" lor twlv.. Ii..,i,s.

"II ailiiiisNioi
t<.|i(ii.|,ii

-U<- lia.l a M.,ia.,v],al .lisl,.,i.l...l. ,i«„l al..l..iii,.|i „,,,,

« i„....iiy I.. ,]... ,i„ht of 11... iMi.i.iii,,,,, ...,;,,..||.. ,,,;„'

=r;'.j';;:;;:;:.;.r:;:-;:;.i-:.;...;;:^

='ri:::;::i-r''';;:::;;;-;:.r --■'--::

::i;:^.;::i:::::;ir::.i:-:.:- :: : t^^r^

-.•...■.1 ill... ,1... ,...,vis aiai I..,....;'.;; :.',:';,. i:^Tz::'':T

In anotl„.r .as,- thnv wa. no ...xn.Iaiioi. of M.u,| i„ ,|„.

'"•"•"»'•""• '."',»''^'"'«'<'"'^-" "as o,H.,K.,| an.! ,1... op,.,.a,io,.
uavf <.M.,.at rcli(.f. |"iaiioii

.1. »;.. a <.(.a..|,inaii aj;..! ,V,, was a.hiiiii,..! ^ <>m ,||,|v i-. ,,,„i ,. r,
Tl,..,-.. was ,i„ l,i.,„,v „| .,„,. p,,.vi„„, alMl.MMiiial alta.li Tw..ntv-

II..- lace wax flushed, feutuus pindied. .ah au auxu.us ..xpn-sMo...

90

THE ACTTE ABDOMEN

r J

lit I. :

H. I ^ ■

luls,. KM.: n.s,„nUion. IH; tniiiMMatiuv. !.!. . TI,.. alulom,.,, wiis
kM.iI.v andsym.,u..n,.;,ll.v<lisi..n,l...l, ,ij,i,l, an.l anuHv t,.n<l..r all ov.m-
Ih.; i...rn,ss,„„ „.,t,. wa. tyiupaniti,. an.l ...xa.ninatio,. jravr .i„ wUh^u,;'-
ot lice (liiKi.

lii.Msion in l„w...- rijrl,. J.alt ol ahdonien sh,.w,.,l a normal apiM-ndix •
ii s..n,n(l m.MSM.n (,v.m- fho stonia.-h n'v..al(Ml nothing al.no.nial Th..,v
was n„ („■,. fluid. During his r..sid..n<M. many ..xa.ninations wr.- n.ad.-
..I t .<• patient l,u, no , aus,. for tl„. at t ark was found. TIumv was no
<-ontnination ol tlio pain alt.-r oi>cration.

The advantaR.. of early o,„.rarion was ..videnced l.v t]i,. unsurt'essful
n-sultot a sniular lino of treatment earried out tor a patient M
aK'Ml ;..,. on l)ee,.ml.er .-{1. I'Mlt.^ T]ie a'.domen was distended, witli
tenderness ov.'r tlie sijrmoid. Temperature llS-8 (pulse !»(i). Tliere was
no fluid or .•aus,. found. The illness had eomnieneed on Deeeml.er •>;
the day alter takinsr three pints of eider. Abdominal i.ain. e.mstipation"
and vom,fnij.r The man. who was very ill. ,li,.,l next dav. \t tJi,:
neeropsy. iM.yond th<- i.eritonitis. uliieh was purulent in the pelvis
nothmjT al.normal was found, .ludjriu^r |V„m ,he other eases an earli.T
o|)eiatioii inij;lit have saved hini.

Of the varieties .,f ixTitcuit is whicli n'stiit from an acute
bacterial uuasi„u through th.> l)l,.o, I -stream the following muM
be lueiit lolled. "

A. P>,e>n,>ocarral. ~Th\s form of peritonitis is not frequent
nhen compared with the peritonitis which follows gross lesions
of the alimentary canal. As a vulv it is not difficult to differen-
tiate the two unless by any cha.uv the signs ot the infection
are most marked in the right iliac fossa wh.-n the i)atient
oomes under observation for the first lime. The jiatient in-
most frequently a child (Barling gives 7:! per cent, girls), whose
parents tell a. history of some iccent chest tnmble The
child was apparently well when a c.mplaint of pain in the
stomach was made ; vomiting followed, with fcv(>r and diarrha^a
There are found some of (he usual signs of peritonitis ahead v
mentioned, and the child looks Hushed and ill. Distension oi
the abdomen is often present with g(-neral stiffness and resist-
ance of the muscles, and this may be associated M'ith dulmws
m the flanks.

Ol)erative interference is indicated, and the appcndi.x
examined in the first place. A perforation should also be
sought for in the adult, in the stomach or duodenum The
best incisicm will be one through the right n-ctus slu-ath with
outward displacement of the lower ])art of the muscle The
exudation, which is abundant, shoukl be removed with gauze

;-.-T>"Tzr».

PKKITOXITI.S j,j

Ktri,,s and soft spong... ami a ...,..|.,.z.,| draina... t„l... pla..,.d

s.iMiU' lluid <<;ivcn prr nrtnw.

In this, as in all f..nns ,.f pmt,>„iti.. it is w,-ll f. ohfnn i
culture fro,,, tl,.. .|„i,l (odou,.|,.ss i.. p,.,.un,o..o....i,. . ...^ • .J
^^ 1^-nt. so that a va..n,.. .,,ay h;p,vpa,vd fo,. funuv :':
the I, '";?' r" ^Tl'^ P'><''n"o„ia pn.>..„t. a,.d hcTp,. of
K hp... Ba,.|,„g ,i,v,dc-s this typ. of i„lla„„.,ation ,f ,h,
pcntojioum into thm> dinical t vpcs •--( i ) \,.„f,> ,., ,. ,.,.
in«n,ar,<,.,,al.do,,,i,,alf.atu.;^f..o,,,*;i.'li:;;;^ ™^
"^''^•'; l"HU,noc.o,...al k-sioxs ..Is.wh.n.. (..),v,s.s in , j '

sn..ulta,,..o..sly.o,.al,,,ostso,.vi,hth..o,^ofp,.H , :'':
l).™n,„a d.vdops. (:!)Ch,-o„ic. s..pti,.a.,ni.. ,.al. •*'

It 's c.„ly ,i.ht to a.id that I),-. lU-.iov (•a,„..,„n is a<.d„st
afK.n,t,o„ oxc..,,ti,.. i.i ,.as.s of n-sidual ahs^.-ss. 1 .an ,

'"•.''^- '"r'--''- ♦'-• - ♦'- '-.i-.nty it wonid b. wis t .
•I.--.. a,ul so ,., rid of one sounv of tl,.- toxa.nia whi.h is tl
great danger to life. A ..asc- whi,.h was under the <.„.'. f , ;
^■olk.ague >rr Hetha.n Kol,in.,n- gives an exeelient clinie d

m.ure of prnnary pneu.noeoeeie peritonitis and sho J H '
v.viue of vaeeine t,-eatn,ent. eo,nl,in,d with operation.

J..I'shI;k;^'" '• "'"' '"'■""""' "" -'»"■• "• •""^- '-'cl-- '1- <'an. of
sli.' hml always Won a .umvous .-hihl. sul>i...., ,o l.ilious .„aH<.

-'f ' "> ■■'J' <■!:.:> ™:;:;h. r :;,;■;;-: ;^;;';;,;"".;-

l..,l,,. „,,. ,:„,. „...„N„. ;„,.! ,„ „„„|| v„|„„„. : „., ,.,,,.' . ','

i;l:;r:-i;;::;:\;::-;-::lt;,:;:::;r::,:;:: !:;--;»:;

I :

!)2

THK ACITK ABDOMEN

! I

i

II'

il

lump could 1).. f.-li. /V,- ,rrl„m lli.'iv was ii l.oj;f;y U'i'Un<t. •■siw.-iivllv
on the li^Jit si.lc, m if i],,.,-,. was somclliinj; lu Itouiihiss immkIi. ' '
Mr. IN.l.iusou saw thr chil.I at 1 1 next nioniiiifr. Ii.t jmiIs,. ihcn I.ciin'
l.-.(i and f..nii».atuiv l(i:i 4 . Th,. alidouiru niov.-d laiilv well <.u
msiuialiou ..x..i)t on tli.. i jkIiI side l.rlow ; luMv aud across ii„. l.ladd.-r
ivfiwu s\u' was i<.ud.'r. Then- was a litll,. riiridit v ov.-r the rLdit rectus
lioili l,clow aiKl above the unil)ilicus. An iuiiiicdiat.. o|M.,ali..n was

dcculcd (Ml. a.s her condit ion KUjrjrc^tcd a pcrlorat iv ,■ peril onil i> dci».nd<'nt
l)rohal)ly on a jransreuous appendix.

(>l>e,ntion.^^T\w risht n'ctus was displac.d inwards. On openin.'

the p<"rnoueuni a greenish-yellow fluid escajied. of Kuniniv consistency"

with a few Hakes of dirty-white lyin|.li in it. .Mtho'.iKh this was

K<'nerally dirtn^ed thiouyh the cavity, and th<- int.'stiiicM and omentum

were smeared ov.m- with it. yet they did not otherwise app< ar to he in

any way altc'red from the normal : the appendix was ahsolutelv

healtliy. .\ jrood .Umj „f (I„i,l i,;,,! ,.„|!,.cted in the i,,.|vis and in tlie

rijrlit kidney jioucli. 'IJiere Wiis no sisn anvwhere of jrluein.. KM^cther

of the intestinal coils l>y early a.lhcsions. Th.. rij;ht l-allopian t uho

was very definitely injected. (.•;iil)se.|iient imiuiry elicit..! no .■vi.l,.nc..

Jiast or iiiv.sent, .,f any vulval or vafinial dis.-Jiar;:...) 'jJie j;lan.ls alonj;

the ilia<> vessels ami at the hifurcation <d th.' a.irta apii.'arcd to he a

httl.. enlarjre.l. Th.' ix.rit.uiea! fluid was .piite o.h)url.',s>. Drains witJi

wi.'ks weiv i)la I in the pelvis ami in the ki.lney jiouch. ami th.' main

part of th.. woiin.l was .'Ios.mI in layers. She sfo.id Hi,. op..rati.m verv

well, and was jnit back t.. I)<..l in the Fowl..r position aii.l uiven ' ..rain

of mo!i»hine. Saline was or.h.r..d /ice m/ioH. " ' " "" '

Att..r th.. .>perati.m th..re was a j;,.nfle droj) in the (..niperature to

!tO- at 8 o'clock the next nmriiiiiir. with a covr<.sp.)n.linjr marked ri.due-

tiou m th.. pulse-rate. Sli.. was f.....linj; much more comfortable, and

there had been very little pain and im vomitim:. she was giv.-n milk

and water fre<pi..ntly in small .|uantifies. On Ai)ril 2.5 her con.lition

Wiw very satisfa..t.>ry, Imt both jmlse ami t<.mperature had airain ri.s<>n

a httle. As lier bow.-ls had not acte.l. .she was put on niamu.siinu snlpliate

111 theevenin<r. The next morniiij; tln're was a v.^ryslitrht result after

an (.nema. The wi<.ks weiv removed from th.. tnb.'.s. and a ..ousid..]-

''lams

iiv.'ii at

abl.. discharge of tiirbi.l fini.l ,.am.. away. Calomel. 2 ^. ....... .^„,.„ „,

iiijjht, foll.)w..d by magnesium sulpliat.. in th.. moinin<r: tliis n'sult.'d
111 four a..tions diirinu th.. day. On this .lay (April 27) the temperature
ajram b..};au to iro up, and. as the .•lini.'al n.port showed that the
p.'rit.>n..al etriisi.yn wa.s a pure cultuie of th.. ])n..um.)coeeus. it was
decided to use piieiimoco<.cic vaccine. On Mav .-> b.ith diaina"e fub«.s
were remove.l and jraiize drains substilut(.d. TJi.. .Iis..liar.'e'".liil i„.t
.•ease alto-rether. On .May 27 a count..r-op..iiinn was niad.. Tn th,- loin
and a pi..ce ot jraiue pull..d through fr.)m front to back. Tliis s.,oii
ha.l a marke.l ettVct both .)n th.. .lischar;,'.. ami th.. t.inp..ratur... On
.hiiie (i th.. front wonmls w<.re heale.l, an.l on th.. loth the drain was
l.'tt out b..liin.l. Hy this date her t.'mperatuie ha.l b..,.n normal loi'a
w.'.'k. .-.^he was abl.. f.) I..ave th.' hospital on ,Imie 1,-).

B. Stri'i^tococcic. —Thh i^ a very fatal Narit'ty of iH.ritoneal

I'KIUToNiris

o;?

imlimimali'ii. and is inn.) ((.niriKnily m'cii in .iiM's of |)Ufi|(ciMl
iiitVction. 'riiciv is little to he tomul in our litnatiiic wliicli
enables nie to >/i\r an authoritative account of it : most of
the refinances are to eases uhich were treated Mith vaccine
l)Ut in wliicli the exact bacillus at work had not been proved
i)\- the Usual tests. In a case of streptococcic ])eritonitis
imblished In- Dr. Horldidge. of I'inner. the entrance of the
<;erni was by way of the appendi.x. and vaccine was most
useful wlien (■()mi)lications arose during the progress of the
case after operation. This bears out the e.xperieiu-e of others
111 a))pendi.v oases, but the Stn plorornis jiijotji „(•< ouiriis in
the tiuid surrounding an acute a]»])endicitis alwavs makes the
j)rogiu)sis grave. Whether a delay of a few "hours in tlie
examination of peritoneal fluid may give this germ a chance
of killing off the active bacteria, and so appearing of greater
importance than it really is entitled to. I cannot sav.

The following is an e.xam])le of recovery, treated on the lines
advocated, and 1 do not think that there can be any doubt
as to the e.xact Jiature of the germ which caused the peritonitis.

A nuiiriod woniiui, ajicd «(•. was adiiiittcil ^ on .\i.iil 21 ami left on
JuiR" an. Kill.

On tli<. luoniini;- ot .Vpiil ir, sli,. wok., uj) at 4 orlo.-k tcclia^; v<m y ill.
Slic liad j;i>'al pain an.l icil lliat a ••onl wa^ iM^iiii; diawu in amnii.i livr
ImkIv. Slu; Iiail .lianli.ia all (lav. Iiut was not sick. The two lollowiiiK
days sli,. was l.ctt.T and was aM.- to do a liltic woik in Ilie Jioiw... laa
on the liltli she was not so well and went to sec a do<loi-. ,<lic was in
givat pain, hnt did not snIlVr from diarrh.ca. She was atlvis<.d to conic
to the hosjiital.

On cxaniination the patient was lyin;: on her hack witli hw kin^cs
drawn np. in very jrrcat distress. \\uv p-.iU- and anxious. I..atnivs
IMiiehed. Tenjiiie Innvd and dry. I'idse. Ids. j.oor volume and ten-
sion ; n'si)iration. 2S ; leinpcrarnre. l<t2H .

Th(> ahdonu'ii inov.'d very hadly all (^ver and was not iecahl v distended
with general ri-idity ot innseles. Teinh'tness was invscnt all over!
especially at a spot under the ri^dit rectus, just ahove th<. level of tlie
uinl.ilicus. The note was tympanitic in the iiinhilical region, hut tlieiv
wa.sshitti!i^r,ltilness in the Hanks. Javerdiiliiess normal. I'elvie oiv'ans
a]»i>eaieil i|uiti' normal.

The same afternoon operation was perloiined. an incision heiie'
made Ihioiijjh tlie rigiil nM'tiis. the ii])per part reacliinu I lie area ol
fricatest teiKhMiiess. On openiiif; tlie peritoneum a ipiantitv of dear
tliiid eseaiied. and a >.'reat deal more was found in th.- jielvis esteiidinj;
also into the left Hank. Seatteied ahoiit on the suifa.'c of llie p.-riioneiim
Were Hakes of yellow iympli. ihe appendix was lemovcd. although

I'S!

ii

94

THH AcrTK ABDOMKX

cx.im,nu.M,M slM.w,.,! ,t to i„. .|.,Mn.n.ly normal. Notlnni; al.iM.rn.al

u.i,s loui.a ,n any im,. .,1 ,h.. al,.lom..n l„.y,m.l this tlui.l. ..t,.. Two

«.MMl.s,z..,l ,l,u,na.«,. ,„|,„s ,,,.„. ,,lar,..l i„ th. alMlon.,.,,. on. l...in..

. -,.. npjvunls nn.l,., ,;.. Iiv..,, ll... oil,.., into ll... pHvis. Tin- wo,,,,,!

ll.«- llui.l R.tnov.Ml a-„i ..xiiminnl in tl... clini.Ml lal.orato.y was ■ S,„.,,to.

Sotn.. .lis,.ha,K,. ,.ontin„...l Iron. .Ju- .l,ain:.;r. t n.M.s. and lal.-r tron.
h uonn, ut.t, ahont .May 11. ,l...,v l.-in, „.a.lnal ...u-ral .n.p.ov..:

w . ; ; , ''""■ '"' ^''"'"^^ "'^^ '"""■' '" '!"■ 'i'-'"" '•"tto...k wl,i..h

«■.:',','■ V '*''";•''*"" '"■'"^' "•l"'^"'' '"<"<• 'I""' .'M..,. ; nlti.natHv

ir «as mr,,s,., , l,,,- a Ion. lim.. this ,lis,ha,-.Ml. th,. acliv. in. I., in'-

.■.•l.o,1,.,l as th,. Sir,;, lorn,;;,. ,,!„„,,.,„■.. \ va-xirn. was tna.i.^ an.l nsvA:
May 1« : ll.,-,7.-,.(MMi ,„,.,i.

1!) : lU.diMi.diMi
2.'] : I,'),4<Ml.(MM»

o.c,

.nun'

-' : I'.'i.tMHI.IMM) cocci.
<i : j;!.<M»(i.OMl) ,, 1 c.c.
12 : 2:i.ti(HI.<MH) .,

h I, was no hnii, special to ,«po,t on the case l.cyon.l .■ontinnation

h.U he alKlon,„:al w.M.n.l was very slow it, healing., .so nun-h .so that it
was again s;,t...', ;t ,n the lowr part on .Ii.ne lU.

A inoiT gcicral ii.tVcti.m ,.f tl.i. blood „f whid, tlio luTitoiiitis
for.m.,l ,„ily a ],art. b.-t was v.-y .s..vi.ro. was the- cas,. of a hulv
agc-(l .-,(>, .siH'u witi, Dr. A. K. C;o(lfn y on May 7. 1!M:{.

ri^' hioilf '*'■• ;'"'^"">"" ^''^^- •^- -mplai.m.g of pain ahout the
njlht sho nlder and .vnetal leeling ot illness. Mxe thot.ght she had

canght ..old. He sen, her t. I. and on his visit .n.vt ,Uv to, d e

temperature nused. and a uplain, o. sotne pai , in tlte lett si.ie .

aMomen. I„ the alte„n.o,t she had a ri.or. Te.npera.n.e, 1,1.'
ihe.c was no vonutinjr. and examination ,„;■ ,e,-t,n„ showed notJiin.r
a mormaK On May .i she ha.l in..,eased and gencal al,,!:,,", n

dst ended rr "ll"' '" '^" '*'" "^^■^ '^''"' '"^'l"'"'"" ^^ -""-vhat
ine liver didness normal.

At 2p.m there was some friction in tlie left chest. J)r. Z Aleiinell

utwaids. A qnantity o. o,lo,irle.ss pus. .encally ,litr,is,.d. I.M.kin.^

ko utieopus. escaped. Nothing was found to aecount for it. tli^

nteal organs hemg gene.ally norn.al. J>r. Dudgeon reported that tlic

.a 1 1 p.esent was the S,,e,„ororrns i>!,o,,ene.. ami anU-«tr..ptococcic

se.um was gM.-n next day. but prod.ueJ no infiueme on tlie pr.MTes.s

Of the disease. At G p.m. of the 8t]i she was w.mm- gencallv. with

evidence of spivading inliammatiou in the left lung. The face was

pm,.hed pulse very rapid ; temperature .still high. b,it no abdo n itl

pan. a„.i no return of .shivering. »hc died four hours later

TKHITOXTTrs

95

In a third chm- which hiui Wvn sriu 1.. a fivcr h<..i)ital as a
case of ty].h..i<l a ..hil.l ,.f li' y.-ais „f agr was vrv ill .,„
(mn-f.-r. H,.,,. the a|.|...,riix appears in have hrn, (iM
alicc'tcil.

Sh,...an...t..M.la.v.alt..rth ..um..Mr,.n...Mt ot .ynii.t,.,,,.. ,l,n in.Mvhuh

tim.- .sh<. IkmI Imtm un.l,.,- tnati:i,i.t. with r,.v,..- aii.l s.,,,,,. al..lo,„i„ il
1"""; '•"': •'!', 'f""'^ ■ -^I'-i' -"'• •!"'•-• ^1..' was v..,v ill wMh ;:,.,„., al

a... apiM.n.hx n.,n..v,.,l, ultl.„M.h ■! a,,,..ar...l n.nn.al ; tl,,.,'. was pus
un.l l.v.aph all ov.t th. p., i,on,.u„>. S,,r,,,„r.,rr„s ,,„.„,,■„,,. was l..u ml
"' I""" '•"I"""- "" '!'<• app:.,ulix a,Hl p., ilon,.,,,,. n<.ar i,. U., wall „;
tli.' =.p|"'',<l>v was a.-ut..!y inllanH-l, an.l n,. „n., „,. . ...a. ,..,nai,u.,l sj,..
.l..'.l i..,n ..xhausti.m n..vr .lay. T],..,,. w..,.. sh...,.s „| v.mv ■.■.•.•nt
l.yn.ph on x\n- pi..„,a lik.. ,h„s.. in ,h,. alMlo.un,; !,„i«s ...i,..,..,,.,l

Kvidflicc ot a KCIIci.iI illfrctioii. ^ -oi.

It is well thcrt't'oiv to rcmov.- the a.{)p(.n(lix in thcs,. cas,.^
as tlic s.HUVf of intVcti.m may he in it. l.iit give no proof
i'xcei)t on niUTosc'opical cxaniinatioii.

V. Ti,/>en;,lo>: rnifo,iili.s.—Ti,v onlinarv forms of tuber-
culous p.Titonitis ,h. not (Icnian.l a consideration fron. us in
(hscussmg the acute alxhmie.i iii the .same manner as ,1,, the
terms of ,.;.r.tonitis which are due to other organisms The
manifestations for which the surgeon is called in are with the
exception of local .supjmration, iiiehided und.-r other 'headin.rs

(.\) There may be obstruction of the bowels, followim^
adhesion of a coil of the bowel to another coil, to theonientun"
or to the abdominal wall.

(B) iVrforation of a tuberculous ulcer (see j). ISO).

((■) The formation of strictures of the bowel. In a case under
care m ll.l.T in which the carum was exci.sed for hyperplastic
tuberculosis, there M-ere no fewiT than eight strictures found
ai varK.us parts of the small intestine which i.roduc-d no
syu>ptoms.

The peritoneum when tub.-rcle is present may, in cases
associated with abdominal j)ain and irregularitv of the bowels
give ri.se to a suspicion of chronic intussusceptioji from the
presence of <me or more tender swellings. Jn the neighbour-
hood of the 'rausverse col.m the rolled-up peritoneum may 1,e
somewhat sausage-sha])ed.

Tuberculous glands in the mesentery mav not only cmuso
trouble by producing adhesion of a neighbouring coil of bowel,

"i(i.

!)li

TUK ACITK ABDOMKN

I

l)Ul wliin suppiiiiitioii extends beyond the eapsule of tli<>
«laiid a localised ])eritoneal abscess fonns. and a fatal peri-
tonitis may ensue if the jnis is not satisfaetorilv limited l)y
adiiesions. These glands in the iliac fossa niav'be niistake'n
for an enlarged and inliamed appendix, and the ])ossibilitv of
an attack (.f acute appendicitis must be remembered where
tuberculosis of the peritoneum is present alrcadv.

An example of the complicated abscess o'f tuberculous
peritonitis is furnished by the ease of A. l'.. ajred l(i. wh(. was
under care from February 12 to Mardi 2. l!t!("

'rii.M.- wii-< a tulMMriilnus fiiinily hislorv and k1„. had l.e.-n tind.T
tivatmont lor ■sornHhiiif; wn.nj; witli lli,. iHt luiiii.- .luring which tin,,.

n1..- Lad had a (..vrish I. Tli.ve .lays UvUnv sh,. •■aia,. in tlu-.v had

ix'.Mi a sudden j>ain in thi" lower ahdoincn. and sli,. was v.mv ill on
admission wiih a jiuls.. of i;!2 and teniiH-iatiir.! I(t2 . Thorc was su.,.
Iiiiiatiou in till' h)w..r ahdonicn not distinctly dr(in,.d. and a fuhii'ss on
the riKht s.d.- ..1 tl... rc'tuin. At th.- operation tlu- intestines were
iound irrefiiearly n.att.d to^eth.-r. and there were intermittent spurts
ot ^'as uid ..rtVnsiv.. purulent flui.l from the d.-.-jier i)art,s of the wound
sJiowiii- und(>ul.t<.d p.Mforation of the bowel wall. Whether this result.-d
tioni ulceration or jiivinj; way of the bowel duriiiK examination it is
not possibl.. to sa.v. .More seaivliinj; exploration was not considered
advisable. A t iibe was inserted, and for some da.vs there was a f.'culen^
discharge, but it gradually diminished and the wound .'losed satis-
taetoriy. When she was discharged we could find no evid.'iiec of
tubercle anywhere.

THE IXFLrENCE OF DISEASES OF THE \PPENDIX
VERMIFORMIS ON THE PRODUCTION OF THE
ACUTE ABDOMEN.

It is difficult to exaggerate the importance of this part of
our subject, the cases which come under this heading presenting
the largest of all the groups whieli are met with in practice.
It is of the greatest importance, therefore, that you shoukl
iiave a good working knowledge of it from a clin'ical stand-
point (Fig. lu).

In the year 1881 we find few records in tlie St. Thomas's
Hospital Reports of diseases of the appendix ; five cases of
peri-typhlitis were under care and one case of general peritonitis.
What are the recent records, not of all diseases of the appendix,
but of the acute inflammations of that small part of the
alimentary tract ? Mr. R„U4Uelle, the Surgical Registrar,

f*

iM-Ln.:.vr,.:„K.u.fKx„,xox,,,r,.:M,„o,„,N ,„

ilU'sc arc its follows : —

'lit III dill'

l\

I'MI-.i -i'lilT .
lilON -I'M*

'r<>t;il (liMi;{ -l!)lo^

I 'u-f .

472
I0"i2

i;-c,,v,ini.

M.

IMr,!.

1.-.1'4

2" IS
.>4<i

T.-.4

.•l.-.;t

4,sl

1(11.

!I,S

21 M)

.U

N!t

Thissiiowslhat of ilu.M. cases (}•>■,;,

t>.esccon.ii.a.fofl:: "„x;'r-:s.^^ -«

;l-^ttl.swnsahvayslii.|.c,.i,|„,,,„,,,,,^

but in tl.c seco.ul half of .he jHrioil

Hkc-n It was less than half, hat .lurin.

['; • 'Tst five years, having fallen froin

•5-!'lKTccnt.toJ5-'pcrccnt. This

'"^y.c rightly aseribcl to the fad
l"^t the importance of early operation

"IS become more gc.iu.rallv recognis,.,!
both within and without the hospital

"-esc few figures fioin one hospital
«'u ; ^^ many will con^incev<.u of the
m-e. for s,H>cial study of tl.is branch
"t the subject, and no excuse is
nm-ssary lor treating it sonu'what
t»'.v- ^ou ca.uiot give too much
attention to the in^estigation of the
nan.festations of acute appendicitis,
or It wdl meet you at c'vc-rv
turn of your professional careeV

more than that von en.,.,./ • "'"^" '""^ '" tl.e wards ;

^^ • '"" ''""'"^ c'xanniie too many of these acute

II

thn

"■ 1". Iiiii-nmi to
tnif.. l,y MiMiliii;, „,.,
rcliiti\c l'r.i]),,i-ti.iiis cf
v:inous I'cif.iiations .,f

thr llcIldW \-is(Cl-„ : .\.

■\li|i("n(lix. Ij. (j^istri,..
''• llll'MJi'ti:.!. |(. lijlj,
I'lr- i;. Jc'iinial. 1'
Tv|,l„,i,|, (;. 'lulal.
II. St,.ic..nil.

•.)H

11 IK A( ITK AHDOMKX

i

i -

^il

laso. Do iiiit |)c >iili>li<'(l tliat \\Ui\\ vim an- tnid hy tin-
])liysi(iaii "V >nr^((iii in cliarjjc is all that can he U-arnt of tho
casi'. Kxaniinc for yoiiix-hcs. and try to draw a conciusictn,
hcfort- tiic alnlonun is optiud.as to tlit- nature of llif Itsioii
present.

You must endeavour to decide, firstly, wliether the case is
one of acute apjx'ndicitis ; and secondly, if it is, what is
the condition of the peritoneum, ^'ou must i;Is(» endeavour

to estiinati- its effect in
tlu- individual, for the>e
east's do not die sim))ly
as a re.ndt of the inllani-
mation— they die from
the to.Memia. .Some of
the apparently mild ones
are very insidious in
their ))r(.gresH, and the
toxins develojH'd ]»roduce
their fatal etfects ratiier
sud'lenly and ujie.x-
pe;tedly. in spite of
oj)eration. if defened too
long. You should all be
able to recognise a case
of acute iidlammation of
the a])])endi.x. although
you cajuiot always .say
what is the exact lesion
of the ap])endix on which
the syniptom.s ilepend.
In the early stages of a serious injury, acute invasion, or
marked lesion involving tlie peritoneum, there will be a com-
bination of symptoms to which the term 'peritonism ' has
been applied. The patient will .■-utfer from local pain, vomiting
and shock. There is then • ost usually an interval of varying
duration, when the resources of the individual are \)eing
drawn upon to enable him to rally from the shock, repair the
lesion, and fight the invading bacterial horde. Probably a
peritonitis will immediately commence, and other symptoms
be .superad<led as the iidlammation extends and the toxins

l'i(i. 11. — .\ii|H'ii(li.\ (hull' fi/f) showiii;;
LiciilJNfd <iiili;.'i(iu' witli t'crfiiiiitiuii
M'ciiiularv til 11 l-'ii'ciilt'omiftioii froiii a
Cliilil (if ;U yours, with (iciicrul
rciitiiiiitiK, lii>t attutk (frnlii " Surj;i"al
] lisca^i's of the Aiipi'iidix Venuiforuiis,''
'Jnd ed.).

IXn-UK.NVK .,K A....KX1,IX ox a, , •, >; v„I.ua|h:x ,.,

r!;;::;.''^ •''•■''" ■■« •■■■' .-.. .,..„

To till- state wl.i(liji(<..Mii)a(iics swell sviiiiil,, in tL i •
i^'H- 11). II may !.,■ u,|,|,.,l t|,a. tiu- n.tur,. i f .

;:::t:;i-r;,.;;;:;!:;v-;,;;':;£^;H

--al.orlym,Motlu.out.-r.si.i...tHH.,.aJ,,. •"'-■"«"-

tnuXrx:!;^ «"

uppreeiab....vc.r.o..„.jt,;a:a';;:.:;r:;::r

pukc-rate. Tlu-rc ,nay In- littl. t.n.l.T u.s „,,,;;'";
duratmn. yet at r,-n,„val of tl.,- apn-iulv ,1 ' * ''";''

coated witl. recent lymp!.. ^^ ' ''" "'"^''''^ ""^^ '"'

At other times the patient mav call out w fh ,.,1., I •
been .uvakened from sleep, and " b.eon..,:, !',';:„ l;;^'"^
.at the administration of stimulants is .s •"'

o« ;r tal!:;;-'-"- -- ^-.r a •;;>.;:;;;-

and passes from that n-.i..,, to th,. ri^ht i • /, "" »'l"'"s.
becomes loealise.l to the- Toot in M? i " • ' '''"'''"' '^

inlying. wi-itisintL.:;.-' .::;;;;;:' ;''''r''t
'•^■"'-^ imt is said to b. loJ down, a, 1 is . , ,;:;;';n'^'

pressure on the right hnver rectus. V,n!^ ^^^ '^^.^
present, coimng on soon after the onset nf the pain iU
contmucs, tJie attack isprobablv of sev.-re chna er '

atUcks of appendicitis there is ^.o vonuting ! I., ! :;:;;^

but there .s ain.ost always a feeling of siH<,H,ss • ' . ' ^
these cases operation is best. ^' i < \( n ni

To these symptoms there are added those of fex,, ,,
quickened pulse an<l n.spiratiou. with a raised temp^- :,..
this IS mostly about loi _l();j ],,,. „,.,,. , "'1"'''""< .

PMicn. look., „,.,,,. „ „,„,, „„„„;';;;;„ i^^ ,;:, ;;«:,:;,„ ;:

u 2

I

loo

THK .\( ri'K .\HiM>Mr.N

' !

ji

I'

III:

i

1'

citiiiiiioii. It I Ik- alxloiiicti i> t'XJiiiiincd. \<)ii liiwl iliiiiiiiislicil
r«'^piiiit((iv muv(iiitiit>. chiilly in tlic luwir purl. It tri'ls
>tilV, tvcii ri;,'i(l. <>p(< iiliy nlxiut tlir itiwcr piiit of the riylil
icctii^. which is lining its duty, that ut ^{uariliiig thr iiillanu'd
l»iirt frnni all iiijurioiis imtvcnitnts or prcs^un-.

'rciidirnc-s may he widi-ly >|»rca(l, Imt i> most rasily c-licitt-d
on pn'»uic oviT till iliac fossa, or. if tin- appci\ili.\ is in the
pelvis, on rectal or vaginal e.xaniinution, Freipiency of
micturition anil dysiuia are jiroent with the pelvic appendix.

It is verv seldom that one can lind itny tumour in the iliac
fo.ssii within twiiity four hours of 'he onset of the acute
ultack ; the rectus muscle pre't-nts e en a distended ajipendix
of (ousiderahle si/c from being felt , there is often a sensation
of fulness liiyond the muscle, and from tlie rectum u tender
lump may often he demonstrated. When under an ana'sthetic
an I'ldarged ap|" ndix may lie felt in the iliac fossa at an early
staif" Some intlammations due to the ajipendix quickly
suhsMic although they begin very alarmingly, whilst others
continiu', and if untreated cause a spreading inflammation with
suppuration, which may extend throughout the whole })eri-
toneum. Often the su])liunition liecomes localised. The
larger nund)er. luckily, undergo resolution, the pain subsides,
tlu- tci. M-rature falls, and convalescence begins at the end of
two or tiiree days. As the rigidity of the musdes is diminished
a • <'l!ing is felt about the ajipendix. w hich ii\ilicates a localisa-
tion of the whole j)rocess. and the illness is for the time jiracli-
ci'llyover. In a fewdays this swelling has cjuite disajijieared.

I'nlos the medical nniu draws attention to this swelling it
is verv jirobably not noticed l)y the j)afi«'nt. anil ^vh^•n asked
in a later altack if there had ever jueviously been any swelling
the answer is givi n in the negative. Although the t«'mj»erature
and |)ulse may be nori<< d, the j»atient is not well until this
swelling has quite gone.

When the symj)toms and hxal signs do not subside but
jjicrease because the intlammation is sjireading. the ]>atient
often shows signs of ijicreased suiTering. He liecomes anxious
lookiug. the ])ulse increases in rajiidity, the respirations are
siJ! 'itiv more frequent than normal and more shallow, the
vesj.iriitory movements being chiefly costal. The tendency
in voung j)eoj)le is to throw ihe arms al)ove the head a. ' keej)

INTMKNd.: (IF AIM-KN-DIX (>.\ .\< I TK AHDo.MKX KM

thorn tiM'iv. Tlir hImIuiihh i, niorv .,r l.>, iiinii.,i,|,.,s. t.ii.l.r
nil |mli.ati..ii ,,v.r u hrp.,. aira. ihuiiKl, mn,flv ... ii, ||,..
iipiM-iHlix nriori: slinni |Hnii.>i,,ri i, ;il,u n-M-nii.! KMi.hi-
t.on i.rnnn.l nfWu nlws n <l..ll nuir ,„ il... .,,,„.,..lix irniu,, . „1

also 111 111.' nv'lif h.inl.Mr n-ij- >,. Tli.iv i. , il.lv .vi.l.iMr

<•> fire lltii.l. >l,ittinn.luliH>. ... tl.r Ihuiks. uhi.l, l.ii,,- <■%(. n.l>
iUT..ssal)..v.-(h.-puh(.>. V..MiitinMisalm.M invarial.lv i.ivM.,.!

a.i.l atf.T Ihal of || „>,•♦ |,„. pasM.I uir a liiil,; |„...„„m-s

• iisfrosmjr. The t..iignc is „Mially fiim-d. aii.l ll... I.nath ..tl.ii
tnul; til.- I.owcls arc .lifli.uil t,. in<.v... hut M.n...|ini. . ,,n
..ITrnsiv .l,arrl...-a is pirsiMit. Wh..,, i, j, ,, lat.- .vinptun, ,t
is«ail.-.|-'s,.ptic,liHrrl..,M.- TImiv is ahvav- sun... .ii>tui I, .n.-,.
oi til." alini.'iitary .anal. Tli.' mil... i> n-nallv M-anl v an.l Iim'Ii
«<'l".iml. at first n.,niial : lat.r it ,nav .nniain alhuinin. I.ul
raifly hid... I.

Tlui- nrv. In.wcv.r. I.anlly any two .a^ > that aiv alik,- in
t he .'xa.t .-ans,. „t th.- illn.-ss ;„„| j,, ,|„. p.,„,.r „i iVM^tan..- n|
tlu .u.hvi.lnal. S.. that in ,.,„■ pati.nt th,- «..n,Tal svn, .t..n.s
an-,,; tiM- jrivat<>t iinpnrtan..-. an.l nni>t !,.■ r..|i...r np"„,. as
an iiuli(ati..n t..r tr.atin.nt , wh.r.a^ in an..th.r tlu- leal .j.rns
indi.'at.' th.- .lan^'.Tous nature ..f the illii.-ss "

v.... will naturall , ask. " What arc th.- si^n.s an.l sv ton.s

t.)l)csp..c.allyn..t.-,l.aft.Tthc..n.s,-t ..f ■• i.,.ritur.is,n •'t,. wl,i,.|,
Mni.ortan.f sh.,u!.l l.c atta.-h.-.l '. .Mak.- all v..ur .-xainina-
ti.)iis HI ..nc r,.utinc niann.-r ; in tlu- first pia<-.- |,,uk Mitl.
attciiti.,,, at the iMticnfs fa.-.-. f,.r y..u niav l,..nn inu.h fn.n.
It. I he .•.,l.,ur. in a .ase .,t aeut.- al.<l..nnnal .li^'as,. „iii
vary v.-ry „,u,-h, fr...M that .,f a lu-allhy p,.r.„n t.. the .lu.kv
ffusli .>t „ne whose respiration is .-niharrasMMl •, th.- .■xpr.-.^ioi",
from a plaei.l indifr..ren.-e to that of a man in m.,rtal a-onv'
Sunken ey.-s. with .lark circles roun.l th.-m. a pin.-h.-.rta.e
an.l Hn.\i.>us exjm-ssion, an- v.-ry ..iniiious. If th.- nostrJK .,,v
w..rkiiig rapidly you may !.,- sun- that th.- h.-art is al-o .r„i„.,
t..o fast, an.l there is v.-ry x-rious an.l ;M|vanc.d .li'^ea-e
prescnt.

The ].ulsc-rate is a v.-ry im]...rtant in.li.at...M a^ to \vli.||,.-r
t le case may he safely l.-ft. it is imi,.-rativ.- to op..rat,- ..r
there is m. h..pe. if >om.- hours j,ave .lap-,,! .i,,,.,. ,|„.
<on.m.-n.-cnK-nt .,f th.- atta.-k. a.,.| tlu- ■ " .-rat,- i> much to.,
high, there is m,thing to be gain.-.l ]n nun ioi ..j.,..-aiion

102

THK A( rTK AFUXiMKX

!';•

it imi-t l»c (Itiiir. Kviiv liiMir l<wt niulii^ I In- >iii(r>< of it Ic^.,
|>r<iliiil>lf. Any acute alMlniniiial cane with .1 piilM- rair dI ovtr
l<M» >li<iiil<| ],!■ can fully Matched : if it cdntiiiuo to ri^' ImaojuI
tlii> tlic piiliciit 11 ()uin ■. -uijiical aid. altlnaij.di other >vni|)ttiiii>i
may he ini|»in\iiijj. The terii)',raiiieiit niu>t lie c'.nMdercd
ill t-tiiiiatinu the sijfniti. niice of n quick jHiUe. fur occa-idiiaily
a ]iaticnt may )te imdiily excited l»y the inedicul vi^it nr he
MilVeriiiH from a neurosis.

The fem|M'rature is often most misleailiiin ; there may he the
most uidely dilTiiscd scj.iic peritonitis, uith a normal or suh.
normal teiiiiMraturc. I'sually. as | have said, there is a rise at
first. l»iit it should hejjin to fall within forty ci^jht hours. A
low or suldiormal tem|)eratiire uith a rajtid ]> Ue is a very had
('(iinhination.

ResfleHHiicss is an unfavoiiraMe syniptom ; so. in<leed, is
a state of manifest iiidilTcrcncf and ajiatliy.

Look for t!ie marks ])roduc(d liy recent applications for
relic'' of pain. 'I'hc.sc will jrjve you some idea of its severity.
Kxamine the skin for sij»ns of intlamm ition or o'denia. Kind
out the charaeter of the pain, its most iiiaiked scat, aial if it
has moved since the first onset, (icnily palpate so as to learn
the condition of the muscles as rejiards ri^'idify, general or
lot al ; also the ])res»'nce of any local swellin^f or undue resist, nice
behind the muscles. Percuss the ahdonicn tlirouglioiit. hut
with a light hand. ])ayiiij; special attention to the Hanks mid
to the ])aits altove tlu- jiubes. If there is any dull area, try if
It is atVcctcd hy moving the patient, as the presence of free
lluid is a sign of importance. Define th liver dulness. Observe
ai-o the extent of distension of the intestines, the jireseiicc or
otherwise of jieristalsis. and wliether this is local or general.
It there ajiiiears to be some distension of the bowel, find out
if this is recent or increasing in amount. A distended ti.xed
abdomi-n without any sound 011 auscultation and obstinate
coii.stipation must cause great anxiety. It is a late and
unfavourable sign in a bad case. l! is hardly nccessarv to
remind yon of the imjiortance of the ];(eviou.- historv. csjieciallv
as regards attacks of abdominal jiain. Vou must learn from
the friends the condition of the liowcls 1' there i.> constipation or
diarrlHca. and endcavimr to avoid worrying the ])atient with
those questions which tlie friends or jiuise are (juite capable

|li«iH

IM-I.l KNCK n|.' AI'I'KNDIX nX Ari iK ahImiMKN im.i

of aii-.\vrriii«. Ill iii..,t niM., ...iir .liilv i^ nut .'.,iii|.|,.t,..|
until \„H havr I. Mii.t iIm- .tat.- of tli.' |ir|y !,■ .nnl.nt., a> |.iov.<|
l»y r.< till ..!• vaiiiniil .•xiituiiiation. in M.nw install..., v,,ii uil|
liiMl mll.imm .tory Mvliiny uii tli.' rinlit -i.l.. „n.l in utli.-r. an
al.noinial airioiint of t.ii.l.rn.-,,. 'ri„. ,. stent ,,f ||„,„. „|||
vary niu.j, w,tli fin- naliiiv of tli.- . a^- an.l tli.- .Inratiun ,,f il...
illn)'»

'I'lif niiinhir .it aciitf aiMl.iiniital (nnilitinn. wiiii' ,•••
^.'.•..nilary (.. .li,fii„- ..f tli<- a|i|i'iiili\ nalnrillv iiiak.', n-,
in th.' tii>( instan.f, .■on^i.lcr •• tli.' ac iit.' ali.iuMi<'i, • fn.ni the
point of vi.'w of that |.ait ,.f li,,. alinimtary .anal. Tl,.-
r.-latis.' |i|-..|)nrti..n ..f tli.. \aii..ii, factoo in tlif .•aii-ali..n of
acnt.- alxloininal .li>.'asc, i, -Itoww in iIm- >tati-ii,> uf the . a-.s
un.l.r .an- in St. Tlioina,', Hospital ilnrii..,' il,r tliiv,- yiar,
I'.MMi :; in,|ii,iv.'. In all tli.r.' w.i.- »,-,(l ,.,-.■,, ,,f Mhi.h' Itis.

or :{■ ii.T<ciit.. .aus,.,! I,y inllaniniati f tli.' app.'n.lix, f,,ini.'.l

til.' lariicst class.

If to th.'M- w,' a.l.l thf fullowin;; ta'.lc ......ipilc.l f,,r thf years

l!M>:t 12 in.liisiv.-. we lin.l this sif.t.in.nt iinirli .■ii|.,!iasis,".,l ; -

.\p|Minli(iii^ ami iirt <oiii|»li.ulliiii.M . I.7S7

litli'stiiiai i.lisiiiicti.iiiH (iitht r til III iiiliis,ii>if|)i i.,ii) i".(ii
liiliH.siis.'i'|itiiiii . . . , ....

I't'lliMiltiiili-i lit the slotiiiich. . . j|,j

iliiixli'iiMni
Otli.r iMTlidalioiH III aliiiiiiiliuy raii.i

.\rUl(i IMTJIllllllis (olllfi I'UllsfH)

.\ciit.! .'JioliM yslilis .....
,, i»ifiri.'atitis ....

tl4

."..I

.■.:(

'I'll.

If Hi'titc iiillamiiiatioiis of ii„. appnidix aiv tlimtoiv
lu-arly ♦.wic- as niaiiy as all the otlicis put lo^'cilai'.

The yrcat iinportaiirc ,,f the nilr wlii.li tl,,- ap|Hn<li\ plavs
is .■k';irly sli.:svn liy tliis til,!,.. Tlif lirst four of tli.. ginup.s'in
this list aiv th. most iniporti;nt of the a.utc illn.^ss,.s and
ivquir. s])(-cial altcntion. Tlicy .iic wmth .•oii>i.|<iation. in
the lirst jilacc. from llic i|Ucsiiun of au'.-. for. ;.'ivi'ii (•citain
.liniculti.s in (lia<;nosis. th.- prohaliiliti.'s will he Tn favour of
iiitus.susccption .luring the lirst ten years of lif,.. amt.' disease
of the appen.lix hetw.'.-n th.- aj;.'s ,",f Ij and :{(►. perforations
of the alimentary traef from Ij to 4(». and intestinal obstnie-
ti.Hi from the aj;.- of :iO upwards, with inenasini; fre<iueii.-v to
a maximum hetweeii ,"))» and tin.

un

THK AdTK ABDoMKX

!: I

h may ho co.uc.led tlml some oases of acut.- a„„o,Kliv
V. hM o, ...sa,,. so severe that ti.eyean be ealle.l ful.ninath.g'

.';::;?■ ';":'T^^'™ = ^'- "^'-«^-<> ai-. but unless v.n

-•V I.Xv'i"^ <-vfuIIy tl.e cry will be unh..;! V , Hn"

pa.M W.I. a history of in.liseretion in cliet nn;rn W

I n'tiiciiiIxT th(. fas.. ,,f ji ,ri,.i ,i„,.,i -, , ,

|-..,]...,. aiUu-U. whi..h was appanMUh- .n S ,^:^;:i:;'''''r'r'' "^

the piiiciits <'(iiil(l t,.|| I!,,, ill . <n,n,i(lci, so l;ii- as

h.'art fail,.,-,.. ' '''" *^""' '^ '"'"^' '""" f"vx.uia with

_^ lnstane,.s of ti.e ,lang,.r of ,1... .lonu.stie treatn.ent of the.e

so,., ..,. •"'"'""■'""'•''•'■-' ~'-".'v. ifm ::

sai\ , the following ease is a good example •_
I'm. on ,h.. n.onnn, o, a.ln,ission. ,ho„, , ^n In h L, ,''" ""^

"'■"' ■ ;"<:■...'!..;!;;::/;.;';■; L':r';: »; :;;,:7;;;;;v,:. i::„ I'l; r,- •"'"

^'''■vv..n...d >in. ni,u^;:;,;::;:i;., :; S';:;.::;;^

?.. 'nr,,:: an!; ;';r ::;:,;:: ,;;j::;i.-.;;';;;L::;;::;:-:r,- ;;r ■"

sn„.oo,,InM.onsofin,.s,ine.in,h,.ilia..rossa;an.l ,,;ivr""S. ' ' ;'^

was ,a,.„.. „s walls w.... .,..,.n.a.ons. Un-.e wL ::!:::;^..ZI!:r^!::

.:'^f!'■r"*i^..

I IXFU-KXCK OF APPKXDIX OX AdTK AHDOMKX ]u:,

I

t:v<-n,- ...Mninj: ro,.,,,! i. a) t J i„,.l, f,„,u i,. .iis,a| ...ul ui.l in tl,..

....^...U,.,... l.„n ,.,. o, „us par, ^1...... wa. a .........al .:,<., ,

a,,p..„,l,x ,]...,.. was a .•..nnHi.,,. v.- an.l an,.,l,.., I„.|, w .^

^'UM. ,.Mo„s,,a,,. ■Il„.,s„l,s,.,,„..„, his,.., y was l.nHlv a. ,„ll.,w " •

•..w..|s a.;,.., „„ ,],.. :„., a.,..r a, „„,.,.,„in.. ..„..„...■ arnl ,.,;..,„,,

. mn^'of ;; "■" ""T '"• '"""^ "••^'' '""^ ^' ""«"'• "i'l' '"- " -
u r; '""7-""""' """'•-i'''- 'lis puis,, ha.l ,.o„H. dowi, ,o I.

tl"' -Hi fJns l.n.w,,. otV...,siv.. vo.ni.iM. ,.,.as,.,l a, :! a..,.. I.at.M- i„ ,1,

-'•!";•" '•'''"■"'•' «■"'■•• ^"V" Willi irno.l n.sul,. a.Hl 1„. I„..a,. ,..
loufior c„ntuuu;l to I,.- a s..u,v.. .,f anxi.My ,., „s.

It is ll,(. casos in M-l„Vh th.T.. is lit)!,. ,,ai„ that ..ft.„ .Jv,.
tlu'frn.at..st anxiety, a slow al...,,„^,n of tl.o poison jzo.s^.n
">" tl... ,,afn-nt appoa.s to b. now l„.tt..r. now not ..nit- mI
w.'ll an.l so tlu> ,,..n.lulun, swin^zs. nntii p,.,!.,,,, tl„- r.tn.n of
vomiting w-ifl, a rapid .ulsr show, that thr illness is , vcv
gravc one. •>

S„„,,. y,a,.s ajjn I saw a pa,i..,„ i„ „„.. „r ■ 1,,.... p„,.,i, ,,,,„„|^ „.,„,

. s ..V l„. iM.ns,. k....,,..,. w„h vano„s ,lo„„.s,i.. ,,.„...,li,.s wln.h s ..

o„s„l,.v.l appn.pn,.,... |, was only towanls , .,,.1 .., ,|„. w. .k ,h

-■ nu..h..ao,„.v,. w.s ,oM ..,,1,.. ..oy's illness. wh..„ I,., was ,". .1 t
■'"•«■" '1- sa-,a.,.,„,„u. II,. l.a.l a ,li,V,.s..,l p,.n,.,ni,is wi,l, nn •

' " •"'- l'-n>.;n..mu. lN.nnis,i..„ ,., ,,„.„.,.. ,'.,,,.1 „.., ,. n

;'"'<; I''"'-"' 'l'<Ml n..v, ,lay. Tins .„...„nv.l i„ a sH,.,,,! wl„., ■ , , !

7:i!:::::tz::ir^ '^'■-

A moiv .-omnion typr of spreading; infhnnn.ati.m of th.-

piTitoiuun, s,von.lar.v to apprn-lix .lis,.,,,, is .hown in tie

oiiowinK a.Tount. It also siunvs tl,o cfT.rt of th. toxins „„

A s,.] .,„ll,,,y. aj:..,l 11 y,.ars. was a.hni,,...!.^ ||,s il|„..s, 1„.„,„ |,„„,
ys ... „,v , la.n.ary Jl, .l.niau ,!,.• .,i,l„. wi,h a,-,,,., pan, i„ ,1 . , ,
si., o, 1,.. a :,l„„a.n ; o„ ,1„. ,oll.,wi„. day l,- w.. „ u,l, w .

II.-

is lloWfls WflC

als.) r,.l, si.'k. and voiiii,.'.! cv.m v,1iimm h,- i,,„L ii
:;ons,ipa,.,.an,.,..n,ai,,...,s..an,da.la,Cs.^
n tW a i.l.m...,. ,•..,„ n,,,.,!. ( .,, a.lmisM,,,, I,- I,ad a ,,i„.lH.,r „, i . ,

""'^•"*-' '-■'■• ^","1 '• -'1 '» ran, in ,1,,. al..l„n,. n. ..In. H i h.

1..W.M. pa,-, ..n ,1,.. ,,.)„ Sid... II.. was lyi„. ..„ his ha.-k wi, h I, ' | , *
. lawn up. 1,.. al,.l.„„..„ did „.., ,„..v.. a, all i,. ,),.. L ! .^

■■V ...s ,.„|y a sl,.h, „,.,v,.n,..,„ i„ ,l,....pi.asn„n,. an.l n,!p p
"u ],a pal...n ..va, ,..,h1..,„..s. was ,.,„n.l all .,v,., ,|,.. ],,,., ' '
.■s,K.,.,aliy ,n ,1„. ,.„,., ,lia.- ,„ssa. Tl„. al,.l,.n,inal ,nns..i,.s J ,' : i "
and a swolhng was d,.,,...n.d in ,1,.. .i,!., iii„. ,.,,,, „,„.,„,„ ',.'-,"•

iiiiji

■s

H

H '■

I II
f! ^t

ino

THE ACUTE ABDO.MEX

froinPoni)iuf.s Ii}raiii<'iit. Tliis My,.lliii)r cdulil jiot !)«■ ddiiifd arcuiiilcly
owiii^r t(. the imisculur lijii.lity. (»ii iiciriission. duliicss was jncsciit
ovi'r this swclliiifr. and also in tlic left (lank. Tlic rest of the ahdomoii
was resonant. 'I'lio jnilso was l(Mt. the respirations were 20. and t)i(>
temperature wiw KMif, . This 7)a»:.-nt was lestless. and i)rotested
vijroronsly apiinst operation. Wlien tlie alidonien was opened pus in
consideral.le (piantitieK was found free in tlie i)eritoneuni. 'I'liere was
nmeh dejxisit of lyniidi on the peritoneum eoverini; the small jiut. which
was generally reddened : in some plac.'s h:enionliai,'ic i)atclie's eould he
seen under this lym]di. Tlie puruU^nt fluid lilled the pelvis and evfended
into tin- rijrht (lank. Tlie a|>pen<lix wa.s :{ inehes jonjr. thick and (leshy.
with pmjrrenous mucosa. There was a coiK'retion in tlie central \^a\\.
and just helow it a minute ijerforation. i)lastered externally with
fihrinous Iymi)h. The iieritoneal cavity wa-s washed out with warm
saline sidiition : a draina^r,. -iihe was inserted, and also a jrau/e strip.
.After the operation tlie jiaLciit's sickness ceased ; his ihiI.m' gradually
fell to normal, hut wa.s still Ins on Fehruary S. louiteeii days after
operation. .\t lirst lie «as peevisli and dilli( ,ilt to jdease. l.iit N-ft the
hospital (juite w<dl on Marcli 17.

You will pi-rhiips l)c oiilk'd u|»()ii to jiivc your opitiioii in a
ciisi" in Avhioli, lor a time, there lias been ji very evident
improvement and tlie I'rieii'ls of the patient naturally think

•He is
various

the dangerous stage is passe j and recovery assured,
so mueli better!' Here you must be guided by
eonsiderations.

We may take iis an examjile tlie case of a stout stioiij; man. aj,'ed .'!.">.
who had Kinhlenly impidved ahoiit twelve lioiiis after the commence-
ment of symptoms. J)r. Yeld asked iik- to see him hecanse lie was not
satisfied with (he iteneral condition. We found him (t went v-four hours)
without iiaiii. I.ut with a pulse of 12u. lie protested very strongly
against operation, and struck his aldoineii virdeiitly with his'chised h>t
to show how well he was and how free from jiain. After much persuasion
we convinced him of the need for o].<'iat ion. and found a perforated
appendix v Mi coniniencin<; sii])purative peritonitis (s])readin<r).

Anotliei way in wiiieh acute symptoms arise is l)y the
sudden rujiture of an emjiyema of the aii])endi.\ into the
genei-al cavity of the i)eritoiU'um.

F. H., a hoy aired 11. was admitted under the care of Dr. .\cland on
Septemher 2il. 1!)0!). It was stated that tli.' iiaticnt awoke ^it 1 o'clock
on the day of admission, complaiiiini; of severe «eneial alxhiminal pain,
worse in tlie riudil iliac fossa. Th.re was no voniitiui: ; the howels had
heeii cojistipated lor thirty six hours previously. It was reported that
the hoy. who was said to have heeii always (hdicate. had hecn quite well
on the previous day. and had eaten .several ap])le.s. .Mthouiili delicate
he had had no previous illnesses, with the exception of fui attack of

INFLUEXf'E OF APPENDIX OX ACITE ABD(BrEX l(i7

abtloiiiiiiiil pain fmii' wt-cks ]>i'ii)r to admisNion. wliich wjis unatttMiilt'd
l>y Kicknoss ami localised itself in the iij;lit lowrr alxlonii'ii. (Mi ailiniK-
(iicin I.c wasatliin. aini'mic lioy. witli a si\ liours" liistoiy of al»loiiiinal
pain. His piilsf was 12(i. rt'^nlar. of K""<1 volume and tension, Itespiia-
tion. 2() ; temperature, !(•! . The atidouien was jiooriy rovered. and
did not move well on respiration. On pereiission the liver dulness was
normal; dulness wife> i)resent in tjie ri;;lit Hank, whieli disapjieaied with
chanjie of ])osition. Tenderness was j;eneral. Imt most marked in the
rijiht iliac fossa. .\t lo..'{(i a.m. wlien 1 saw him the i)uise-rate was I:i2 ;
temperature. H>2 ; alidominal pain more acute. There was more
dulness on tlie ri^Iit side of the alxlomen with sono' over the piilies. tin*
amount of free fluid havinir inereasi'd. .\t this time the hoy was p;ile,
looked anxious and piniii<Ml. (tperation was peifoiiued ten hours after
the cominencemeiit of syiujitoms. .\n incision was macU' in the ri;.'ht
'le of tlie abdomen tliioU);]i tlie rectus muscle, the llhres of the muscle
. inj; separated with lh<' hainlle of a scalpel. When the i)eritoneal
cavity was opeiu'd mu<-li |)us was found in the rij;ht iliac fossa and also
in tlie jielvis. It was thick, yellow, and without otTensive odour. .\
>:a.uze stri)) was i)laced in tlie ))elvis and another in the h'ft tlalik throu<;h
the alidominal woinnl. so as 'o ahsorh pus whilst the appi'ndi\ was
removed. Three rows of sutures were a))plie(l over tin- ca'cal ojienini;.
The peritoneum in the re^iion affected was diied l>y means of i;au/.e
St ri]>s, and the wound closed, with a iiihher drainage tuhe |)assed
through the low<'r anjile into the jielvis. 'i'he jficater quantity of pus
was foiiiul in the rii:ht Hank above tlie position of the appendix, .\nli-
liacillus coli seiiim |2.') c.c.) was injectetl siibcutaneoiisly into the chest
wall befoic the i)atient left the tlieatre. He was ]ilaced in a sittiiii;
])osition. and c(nitinuous instillation of waiin saline fluid into the led urn
commenced. The tutie was taken out on the third niorniin; anil
shortened, liut its use was <'ontiniied for ten days.

TIk' a])pendix was unusually laf;;e. and ]n<'.sei,. ■ a pctfoialiou
towards the tip. When o])encd a strict me was fo\ind about the juncl ion
of tlie jnoximal twothi<ls witli the distal tliiid, which ci>niplel<'ly
closed the lumen of the tube at tliat ]m it. finininu; in this w:iy a cnvily
of the distal tliiid. with which the perloiation communii'ated. and from
which pus was exudiii}; when the appendix was found. The jiatieiit
had had an eni]>yenia of the a|)pendix. which liad ruptuicd without
warninir into the n-eiieral ])eritoneal cavity.

TIk' diagnosis of tlii' exact condition dci'endcd njioii tlic
(wti'cnic suddenness of tlu' onset, the severity of tlie synijitonis,
and tlie large amount of lluid wliicli was noted Itefoic the
o])eratioii, although such a short time had eiajised >inee the
eommeiieenu';it of the trouble. The history of a former
attack of ])aiii. as pointing to pre-existing disease of the
a])])endix. was reg.irded as important.

You must not. however. ))e misled liy a ea-e in which a few
liours after the onset of ' peritonism " the patient appears to be

lOH

THK MVTK ABDOAFKN

!

I ;

'I
if '

..■tt.T. \lways s„s,„.<.t flu- ,K-„t,. utfa.k ^vUH■h appears f.,
iwvc. «r,l wHl quukly; a raj.i.l i.nprovnn.nt in fjcuTal c.,,.-
'I'tum Mil. c.nfn- loss „f ,,ain oft.-n „„.a..s fho giving way of
.n ovc.r.l,s...n,h.. aj.pc-n.lix. A h.Ii is ,al<ing pla.. h^on 'tl.o
■pt. fluul wind, has ,.s..ap..,| tVon. ,1... appn-ciix pro.lu,.,.s
its effect on 11.0 prntoneum. In.t all tl„. tin.e al,so,-pfi„n of
po.son.stak.ngplac.e.a>.,l tl.e next stage is l.ut a sl,o,-, p,,.|u,le
to ca latal ending.

.4>^S,r^ ',""" "' '' '" <■"'-""-'-" -'- i'-l a „„|S0 „f H..;

i.i. fossa. I.,.t „o .lis„..is>.,M. II,. |,a.l. I,„w,.v,.r. a „,a,kc.l iwuluvui

.. attack ot ,,H,n ot H .nil.l ••l.a.art.,-. loll.,w<a l.v .i sm.I.I.,. m- v, ,e

^ ^^ I...... A la,fic a|.i.....,l,x had i.c,i.„at,.,l 1m.v,„„1 a st.i.T,.,,. a.,,!

atta. k. ^^I,...i. ha<l I,,.,.,. .l,a.'...s...l as a,.,K...,li..i,is two y..a.s iM.;vio,.slv.
Almost all s.ngeons wl.o have set:- anything of the treatn.e.if
of appe..,l,e,t.s ,.eeog,.ise that to save Itfe i.. the la.-gesf nun.h,.,
.. n.sta,.ees you must tvn.ove the ap,.e...lix as soo., as possible
after he o.,set of symptoms. The puhlie has n,.t vet heen
•■<l>«ate,l to the nee<l for this, hut n.en.bers of the p'.ofes.i,,,,

m-,,g,n.se,tsg,-eatimportaneeasa routine method of treatment
.Now that the aeute - I.elly - easc-s a.v s.-nt in at onee to th,-'
surg,eal snle. then- will In- k-ss ,|,,ay than there was whe.. tl.ev
I'a.l to i.ass through so many han.ls before thev lea.hed th'e
oi.erat.o,. fheafe. I ,voul,l e..deavour to ..nphasise this
quest.o.. of t.mein the treatn.,...t -a,, hour saved ,nav ....■an

th. re.noval ot a distet.de.l appe..dix b..fo.e th.. p,;iso..o.,s
c-ot. e..ts have eseaped and fouled tl... p< ritone,..,,. ....t ....ly

'" <l'c^ c-eal reg.o.. but also in the p.-lvis. wl...... then- is such 'a

large su.faee for absorption. Tl.e.x- ar,- undoubted n-ec^ls of
ivovenes from a get.eral septie ])eritonitis. but th.-v a.e ..of s,,
•""'H-.O..S as publisl.e.1 ,.as,-s would hav<- ..s b.-li^ve. There
.s a ,1. Here,.ee b..tMee., ■■ .litfuse.l - a.ul - g,.„e.al.- wl.i,.|. is
T an. atra.d not ahvays app.veiatc.l by those mI.o write a.ul
t.-lk about the d.sease. J,. n.a..y if is i,.adv.sable to ren.ov,- f he
pat.e..t to a s.n.gu-al home ; a.. ..pen.f iot. do..e o,. the spot n.ay

^ve weeks ot,lh,essa.,d^

Mould be a, long a,.d possibly shaky o,.e. Yuu Van ,p.ito

INFJAKX( H OF AI'PKNDIX (>X AClTK AllDoMKN lo;»

■3

uiidcislaiul Avliy tlic ixlni iiiovciiiciif would hi- bad tor a
distended Imt still imrui)tiired apjjeiidix. the wall of wliieii
is xmieTimes like moist tissue jjaper.

As a rule you eaii ditlereutiate an acute a]i|)endi.\ attack
from other urgent atTectious of tlie abdominal contents. I will
return t(. this subject later ; but this is the essential to make
up your mind whether the patient is suiferini; from a static
which necessitates interference or not. If you arc not certain
and tlicre is a icasonable ])robabilitv that vou arc dealin"
with an apiHiidix tioublc. the wisest plan is to operate. Sur-
geons who see much of this disea-e can often tell vou the exact
state of the apjiendix on which the attack (lc|)<>nds. This
may be of great temporary importance, for the surroundings
of the cas- may not lend themselves to the i)rol)ability of a
successful operation of any kind. es])ccially one involving the
peritoneum. Or igain. there may be urgent private affairs
to be settled before the risk of an o))eration is tmdergone.

Indefinite or subacute appendix .symptoms coming on in
patients ot advanced years slioidd excite the apprehension of
any one under whose charge the ])atients may be. The signs
of disease may be few. whilst the age and weakness of the
patient make it ina(lvisa))le to do any ojx-ration excepting out-
of a))solute necessity. Yet the most .serious disea>e of the
a]i])endix may l)e ])resent. and a fatal re-ult inevitable, unless
it is removed. X'ague afulominal ])ains. with >omc rise <if
tcmjterature and ])erlia|)-. a little sickness, may be the only
complaint : ju'rliajts even the medical man is not sent for until
there is .vu]u- tdded a tlatuleiit distention of tie abdomen and
a rumiing ])ulse. The following account will show the type
to which I am alluding : —

On Scplciiili.T in. l!t(i!(. I saw a .nun. nnfd 7."!. Inniim tlic nii;lii of
tht! 7tli lie was a\vak<'ii('<l hy piin in llic iilidniucn, Inil did not \i>iiiit.
'I'lio pain wa.s luit severe. Imt lie took some ra.>tor oil. NevI dav. I lie
Ktli, lie sent tor his medical man. who found him with a tem|)eratiire
of 10(1 and -viiiiitoms of a mild attack ot aii|»iidicitis. On the nth he
was miieli she same. Imt his lemiieiiitiiie was slif;litlv raised ; he had
vomited on the jirevioiis eveiiini;. and his tongue was l)e(omiMir dry.
yotiiilif; almormal could 1 • felt //«<• ,f<-t)n,i. His eoiidition at l.'..'!!! on
the Kith, when Wf saw him tojrether. was a> follows : lie was a health v-
lookiiif.' man. with a iiomial temperaliire. ^'ood apiietile. and a jiulse of
88 ; his chief complaint was want of food, and lie did not like lieing kept
ili 'i' Tl"' ilily symptoms of aiiythiiiu Wlolii; Uen- a \eiy diy lol|t;ilij

f

IK)

TIIK ACITK AUDOMKX

l\ li

I

;:m';;:; ;::::ri;;: ::;:;-';:;;r;;:'l-t;:;v:v'»:"" "■^™'
;:!:ri ';:;;, |:;;-:::r;;r;;;;:':;;-;rf^"™'v™^

|MlH ,xh.,l. 1,H.I ii.Tm,Hllat,.<l „. th,. IMTIIOIKMI cavil V.

I< will !,.. ,u.t.-.l .hat tlu-n. was ,.o swoilin^ iu ,1.. i|i,, f.„,,.
ulllKnigJi !„• hail iKi pain.

TiiK Diagnosis ok Ai'i'K\rti«iTis.

Th,. ,lis,.as.s whi.h n.ay b.- .Misialun, i-spcviallv in th.-ir
ousH f.T a..,,.,. a,,,H.n,li,.itis may Ik- k,ou,„.,| as fnliows • -

A Uoranr. having (lu-ir ,.ngiu al.ov. fh. .iianh.a.m.
A.UU- .nHa„una„<.ns of ,1.. low.,- par, .,f ,h. pl„,,, Ja .uL

H. JW.,./.„/_TlK-so n.ay bo .livi.locl inf.. gnmj.s :
th. f . 7" ' """' '"■'•""' «•■'•"'• "*^ ""■ '"^^ its origin i.v

1^ ^ .1 ■ r"'"^'l""^ ■ ^'-tm-uterino gestation ; torsion of
I" pcdu. .. ot an ovanan ..yst : rupture- of an ovarian cvst •
;•';- o th. p.<ii..|o of a subperitoneal tibroi.l. or . „.'
lurrosis of a utmiu- fibroid.

-'• I'l'lHT ab.lon)ijial.-^IVrforation of duocU-nal ulc-r • m-y.
^n-afonot ^astn. ulcr : aout. pancreatitis ; aente ,.ho|.-..; j s
and j.crtorations of gali-bladd.-r ; biliarv .•olic

;{. -Mid. abdonnnal.-Calculous atrtrlU.ns of the kidney md
mvtc-r; n.ovable kidiu-y, producing J)ietrs cn>. ^

4. Inti'stiiia! obstructions.

5. Acute iutlannnations of the peritoneun, from infection
tlirough the blood-stream. "ncuon

|i. (iastro-intestiual afVecti.ms. _ Ejiteritis and gastro-
^■ntc-ntis ; nmcous colitis ; intestinal perforations ^

. (.™l diseases.. Typhoid fever; - abdonm.al in-
'•U'"/a ; hy.st.na; lead colic ; malaria: the cm., of tabes
dorsa ,s : angeio-ueurotic (jedcma ; Fiem.chs purpnra
-Mahunant disease of the ca-cum and asoeiuling colon

ne^"";;. ; t ■" ''•■^'r^'-^':»^''y ^^'^^ -mdltions. an,l it is only
-uccssa.x to remember their occasional oeeurreiice Oth.Ts

tf

INn.lKNcK OK AI'I'KNDI.N (»N .\(TTK AUlM ►MKN III

only siiimliilc appciKlicilis wlicu tl

a localised swi'lliiij^ wliicli can he felt M

le itillaiiwiialioii lia^ |iro(liice(|

the (liaj'i

oreover. Ill (Ii>cii>>im;;
lo>ls ot acute a|i|)eii(iiciti~. i| imi>t I.e leculleded

iver. ill til

Hi ■ o

Illy oassiiij,' Ik the iliiic fossa

that the ai)|)cM(li\ may he jilaccd a> liiuh as the I

iliac fossa. ..r in the jiclvis, \vhil>t the pain is nflen n'fencd t(

the iiiiihilieiis ill (he early st;

later.

e to enter into a loiij; diNcu^>i()n of
which siiniilate acute a|ipeiidicitis,

'oni a
dered

It would not he advisahl

this larye >.'roiip of disc

i^e

I say somethin-,' ahoiit the most important fi

lint wf mil-
practical point of view, although tl
when we reach the special sections devoted t., them.

icv are a^ain co

Ac It It' Piii'itiiiintin. — Thei

e are few surgeons who have not

lieen rcipiested to ])erform laparotomy for ahtlominal svmpt

in this disease which I

The ditiicultv has nio^tlv ari

ptoms
lave simulated the acute ahdomcii.

risen on account of sudden i)ain

in the upper alxlomen with rigidity of tlie musch
vomitinj.'. and fever, symptoms found nl

>ome

a gastric or duodenal ulcer has

en a perforation of
ucurred. In young peo])le
before the age when gastric and intestinal perforations mostly
occur, the resi'inblanee to acute a|)|)en<lieitis may he very
close indee<l.

All instance incut ioiicd hy .\ihiiMs iind ( 'jissidv ' i

in wliicii their was not onlv h lijiid ahil

tniiiiinin;il wjil

nay l>f icIVmciI to
li.il till' i.itc ot

til" ;;ir;Uc>t Iclidcrncss was over .\Ic Km ncys pant.

A careful examination of the chest should therefore he niadi;
in all eases when there is any likelihood of such condition
lieing ])re.sent. as indicated hy the ra))idity of the respiration
in c()m|iarison with that of the ])ul.se.rate. which
more than Ion. The late .Mr. Harnard'-' in his com

I Is seldom
inuniciition

on this subject ])ointed out that direct tlioraci<: signs are often
almost entirely lacking for (wentyfour liours or more.

lie incniions oii« case in wliicli there were such dclinit.' alidominal
nIkiis tluit the alidoiiien was oiicned, whi'ii the iileiirisy was associated
with fracture of the rilts duo to a known injury.

wliicli must be considered here as (hey

The medical disease

will not lie referred to hiter are as f

ollow-

' "Acuti- .\lMl.piiiiiKil I >iMi_';i~i«.'

I'litj Simulatiuiis of .Acute IVriluniti> liv I'Icur.i-l

Vol. 11.. I'JU-'

neiirnoiiio I)is<ascs

Unuft,

1 •

ii:

TIIK ACITK .\IM)()MK\

\. n/,'f>n„l r,nr. Tlu- s|ali>ti.> .nll.rlr.! l.V Krlly .Uu\

lliii'loM show, tn.iM vjiiiuus ^niir.o. ||ial iimnii->l :!:io'<ii...s
"t |Mrluiali,.ii,K<umii«iu l.v|.l.ni(l frv.-r. thi> |Hrl..ni(iun was
silual...! i.illicai.,«.n.lixin:{o. Tli.v |...ii.( ...it that (l)a|.,MU.
"Ixilis may I..- |mivly a.ri.l.i.lal. that is In sa v. aim.inli.ilis

;""' 'M'' ' ♦''■^'•'- '""•' "f vvhi.l, a.v .on.MM,,, M.ala.lio. inav

l»y ar.i.lriil !„■ Inund cniicuiiVMlly ill ih,. >ain,- iii.lividuai.
or a lahul and clironic iiitlatiimaf imi ,,f ih,. a|.|Mii.liv niav h<-
n.UM.I m,o a.tivily l.y ty,,!,,,!,! l,.,,,.. (-) .\i. a,.,,.„,li.ilis
"' •■"""' <■'• <'t a M'v.iv ly,... M.ay ariM' irn,n a tv|.l.ui,| atlrrtin,,
••I 111.' lymph glands ,„• tn.in ,n. uIct Mtuatcd in tli.. apiu'iidix
■"•<l may ,.vi-.. p, ,,,1 lu |MTtn,alio„. (:t) .\,,,».ndi,ilis mav
t..lln\v lyphuid fcv.T. apiKMriiij; uithi,, such a hii..t time aft.T
ll.r sulM.I,.,,.,. „f Ih,. tcv.T as to >„..,.,, ,., ,,,us,d ivlalinn.hi,,.

It i> ii Well (■s»al)iishcd fact thai a true Ivphoid atVccticii „f
the -lands „f the ai.pcn.iix ..ccuts which n.av im.cc.d t.)
"■••'■'•'tinn an.l >ympt.Mns in the riuht iliac fossa n.av in.lucc
the sut-rron t.i perform an opcriition fur the removal of the
appendix in flu- .Mrly stafie of ty,.hoid lufore then- an- anv
dchmte sympt..ms of that disease, or in.hc.l any possibihtv
of diai;nosini; it corii-ctiy.

If there are. in aihlition to f.-vcr. the iisn-: signs of ai.jx.ndi-
c.l.s. diac ,,ain. tenderness and ri-i.iitv of muscles, it would
be best to operate, for it is far bett.-r to remov,- tl„- apj.endiv
l>y an oiHTatiou. which should not in anv wav distress the
patient at this stage, than it is to h-t him run unnecessary ri.sk
Curschmann has (h'seri bed a eondit ion occurring duriiHr t vphoid

winch he has caM.'.! •■ peri-, orpara-typhlitis tvi)hosa. "in" which
a minute ]u'iforation is f.mnd in the carum. or between the
eacuni and colon. In the.se perforations swllings are found
which cl..sely resend.le (hose produced ))v ai.pendix iniiamma-
tion going on to the formation of al)scess.

Occasionally a patient with a concealed abscess or a suinmn-
tive peritonitis due to a diseased a].p..n.lix comes under
observati.m with the diagnosis of tvi.hoid. Th.-se are usually
those cases ,n win,']., the fever has been .slight an.l the local
^vmptoms somewhat imlelinite ; i)robablv the ai)i)endix has
oecui)ie.l the pelvic jiosition. whilst the iliac f..ssa has been
free from tvuk'nt change. The result of absorption of septic
])roducts may jiroduee a ■' tyi.hoid state.- Widal's test must

mmsmi^

W^MM^^^i^K^^lMMML^

i

iNmKX(K(„.'A,.,.,.;M,ix..x \,,Ti: \Mi„,M,.:x in

!"• »rH..I a„.| a ..arvful ,hMly ..X., „i a-l. „, .loul.,f,.l

;:'-• ''^■"'""•■"'-" "♦•l'<-l"l...n..,. uniu>u.llv.l..l ,1,..

'••-..,■.. oMrn.||„,.lnMl,.. ,...,.,, .,.„,. a.-l ;, .I..' „.,..,„,„,.

a r.ijiid. fcclilc |)|||m..

»l.<l. I lMv..|,..,.„,v.,n...n.,| ........ a, M.i..„. thnvl.a.I...

'">ln.y «,v..M ut a..a,k, „f ,|„|.,„j,,,, j,,,,,,,,,,^^, ,

"'••"Hf...|,,.,o„> of ll.is .li^rax. iVuC.M.r (),|,.r wri... ; -

i.Hnaui.^:::'Z':t:;^::';:':; -"7'""'-^-"^ .w,,,.,!,..

.-no., .Mnalnuli..!!;:. " """■ ' ' ^'^^ '^'" ' '"•

•11 .1

It
llllt.
1

-n,,. ,lu. ,,r,.val..,„.,. of iMll„..,..a a, pati.,,, with a .li..
;,:, ' ""^^; ;;""Pla.M ..f a, s,.v..,v ,,ai„ i,. tin. aJMl.-MMn. an.l vn,n„

';:r^^'''''';'''''"'7'''- '''•*'"• -"-•n,i,litvo,.|,...a ,

♦:■••'■.•.,..» of ap,„.n.|M.itis. (M|.,.,s „. „.,. ho,.;., n.av la

-.».,. attacks. Th..y arv so,,.,.., s ah.,-, ,. ,, , .

..su.lly p,oh.„„..l. a„cl a,... a..,.o„,pa„i..,l ..i,h%. ,..

:i. ////.v/o/a.-This ,lis,.;,s,. ,„ay si,„„h,t,. app,.,„h.iti. -is
•";»t ..t us kuo^y. hut it sh.M.I.I „.„ U. p...il, .. „

lo ,,iaK(' a

'!'• 'lail iHit hail

mistake

A imi-M. ,„„;■ .am-, lo lia\.. Iin app-n-lix ivPiovrd

:;;-"<« s,.,.,.n.al,v.. p..,ilo,„l,s. ami si,.. J. H-n, n .^ I' '''V'"'"

tli.- M.as,.!,. |„, ;i ,.|,ai «... \\1,..„ ,1,,.,.,. sl„. wa. >..,/,.,l „
•a^.Miisi,,.- ,,ai„ in ,!.,. ,i«l„ |„„,.,. al..lo,„.. . „ ., '" ""'"

:rl:::: 'i'':.r>"- -•' -'-■v.>-a,,..;,,;:i,J!:::::;';'\;:-.;;:,

"'""''"'.' ot ,1,.. aciil.. at, ii-li- II. .a.,,
.lix- ,.0, 1,....,, ,..,„ov,..l I think it woal.l hav ,, .v..i ,'"'*'"" '

-f «he attacks ol, mil. which she ha.l ha'; ' '^"'''"" """

\.A.

'^

[ill

Ifii

l! 5
I

111

TliK .\( I TK AJJDo.MKX

rniff^or (»>lri ' >iiy> :

'■ 'I liiir in a v\)'ll'kliii\Mi ' a|i|M'iiilii'iil,ii li.V|H>(lmiiHli ia-1-.' 'I'lir uoixl
^•a^<•■^ III lhi« riaht whirli I liaM' m-cii lia\r Im'cii in iiii'IiiImtm iiI our
piiili'ssiiiii, anil I know ol al Irait one iiiotant'c ni wlmli a |M'il<'<'lly
iioinial apprnilix was irniovtil.'

I. Ill Li ml ('ill ir llic pain i- nciii'iiil paiow -ma! ami iclicvcd
hy piosuic. 'riicic riiav lie vomifiiij/ willioul any ii>f ol'
(cnipciatiiii'. 'riic i)t'('ii|iali(in of the |ialiciil. Ilir piorncc of
a 111 lie linr on tin- j:iim-, with ot lice >\ nipt oiii> of Icail jioixmiii'i.
>lionl(l jiicsciit imy ini^lakc

■"». in llic j;a^(iic iii>t> of Tnln s hnisnlis lliirr may Ik-
Mvcic pain in tin- (■]ii^a>tiiiini and vomiliii;;. ami the attack
may hot for >onic days. The attacks aic variahic and may l»c
cxticmciy sc\cic. The loss of eye and knee idlcxcs witli the
history iiiid ])rcs<nct' of otiici' symjitoms should make the
diagnosis clear. Tlii'se attacks more freciueiifly jjive rise to a
mistake in the diaj^iiosis of -tonmeh ])erforiitions than in
those of the ap])endi.\.

fi. A malarial attack is very \n\common in this country,
heiiifi rarely met with e\ce])tinii in those who have lived in
a foreijin country or one of the colonies. Severe alidoininal
sym}»toms in the su})jeets of malaria may simulate a]>])endici,is.
and without ojieration and e.xaminatioii of the a])])endi.\ it
will ]ierliaps he dillicwlt to say with eiTtainty at the first visit.
If the sym])toms mentioned ahove (local pain. t<'nderness.
rigidity of muscie and fever) are kejtt in mind, there should
not be very much dilliculty.

'I'lii: 1{i:si:mhi,an( I', ok Diskasks ari.sinc ix othi:k Okcans.

1. Of the jielvic causes of the acute abdomen which ])roduce
a icsemblancf to acute appendicitis, the majority are easilv
dcmoustrate.l on vatiinal or rectal examination, the ])resence
of a lunioiiv beini; readil\ found. Sometimes a tumour I'ises
out of the pelvis. Should a cyst of small size ru))ture. then
the e.xact condition mav be ditlicidt to name, but va<Mnal
examination should show a tender swellinj.' on the right side if
the ajipendix is ])elvic and inllamed.

2. Uf all the conditions which arise in the ui)])ci' abdomen

I •■ rriiK'iplis aiicl I'l-actici' iif .Mrdicinr," |). \\".

;^;:""; ;■''''■'" "":"^' "'"»'••"">■ .>.!H.,M.,f,...,„..., .,„..,.,

•' <-t .la..... v..r, I,.. .,,,.,,,.,. h. ,l.i, ,,„„,,„,..,.... I.,..

';' ''',7' '''*.'•''•■'^i-'•''H•>-i.l.^..„.m,.^ ..,!., ,,.,„;,'

w;;i;'ii::;:;:;;."i';;;;'- ••••••• >^"-- --".,. ...,..„,,:;,

•f. •^♦■7:Y"'''l>m,.yl,..-...n.llM.n.al,..,.t,|,..air....,,.,n...,,|,..

p-^^ ...,.,,.. ,n,.....| ^. n,,. ri.h, |.Mn..y. an.l ,h..n i, in..,.. .;^
tiv.,..cM.y at nH.f,iriti..M w,il, lK,.,„aC:,i , \ ..,|,„|,.

, ., , • ■ '-' ""'•II it >f<>iic liii> ((■.■11 ,irr.-i,.,|

i.>-.Tiir..s,s. .,ii,.„ „i.y .„„,,,. ;,,., ,,,,,.,,.,;'':.:•

. S...M... ....,„...■„„„ ,1, „,, ,i,,„ „,,,„, ,.,^^.„,. ^ :

Ku<- «.oaf alarm l.„t mn.ly ,v,>,.,.,„..,„ ,„.■ HiMin.l pi, v
nt <wut,- a,.,M^,i,|inf..s wl.i,.|, w.. I^vv alr,.,Hv -nvn

...::''^::?:;r;::;;t:^v!;;;::;7 ■;:::';■-::;:':,
r::;;;;;:,;r;v,n^;' '-"- '^ ---^

Ml I. Tin. K Cm.ciii I\ iiii' Fii-.. I.-.

f--'lc- I.ati..nt. ..«.■,! .-m. was s,..-, l , i" ,• .'^ ';;'"••' '"-'^ ■ A

l.>lI.I\Vlll}f iiisti.iv. \l.(,iil t,,-.r V ■ , '" "^ ■"I'l Hitvc the

-n...k w.,h pain in u,..;:;,.,:;,.;;:::.^;';;,^; •■'-'•' --i-
'"— • ..,.>•....,;;:':;!:;,. ;:;;:':; r /";;;;; "':-'-••- >

a^-ain with ,,ain in tl„. ,i.ht l-.w..,- , ll -'Mn.. .|„. l.,.,,,,,,. ,||

'••-"•-•■••'I. -i,i ,w,. .,ays ;;;;.,::.;;,;:: ^;;';";"":, •'■"•' 1';'-

on.un. 10. Oiitlu. l-'tli sl... «•. "" '"•'-■"I' Hi •■""llnvsawli.r

"ft ""t •'•-<;!;:■.:;;:,::;'::'• ;';::;;;;''::;i'';:;- .;:•-

'•■•"IH'-atur,. was 102 . an.l tl... ,.„Im. ,a, i. ' tl' I ' i;"""" ' '"'

;::«r:;r,s;:i,-;;d;,;:;,[i,:,i''r'"S
;;;:::-l::^=-;rl:;:=:':;;;:;:d;r^^

^''"""■"'"''^■'^ "■"""""•- -''-''• '"■>'''''i''ns,a,Min:i:;ai;..anM;;:;;i::;;

I 2

:3'"i;' ■ir»^'fMi'Jl*&V^■^■ -^ i

no

Till-; .\( ITK AHOO.MKX

\Mf llt'lIJllivi' Till- IiiiWI'Im well' icill-ll|lilti-<l III ;l iliiv iil tWii till'

•>viii|itiiiiix >iili«ii|i-<l, liiit ri'tiiiiii'il Willi '•■■tt'i'itv, ~ii '<li)'\\ii-> si'ii* into
liiitliitiil on tilt' llttli.

TIm- iilMJiitiii'ii \\ii« tlii'ii vi-iv triiili'i all iivi'i, lull not liulil. Nnlliin^

mIiiiim iinii I'oiiiii iii< r<>iiiiii. 'ri'tii|ii'i,iiiiii', iiMi li I'liUi' I'jii riMit.'iiii

"till liiiiiil ami lirrath Iniil. S|», ui ..f nilni'. Iiilj. Aiiil, lie. ivy
ili'|)ii->it III iiratrH, nil alliiiinjii Tlir a|>|ti'ii<li\ \\ a« iiiinix I'd, it wa*
liiiiliial Kvaiiilliatiiiii iil il^lil kiiliii'V, it\aiii'» ami ti|l>r-< xhnwiil tln-iii
III lie lirahll>, tlir lllrills \va» li-t invri Iril Altil tin- ci|iriatliiM -lir
viiiiiilnl a uiiiiil ilral. alimi^l I'liiitiiimiilolv Un \\\<t <la>-, liiit tlir ti-iii-
|M'iatiiii' caiiH' (liiwii In iiiiniiai. 'I In- W'ltlal ti'->t Ini' t |iliiiiil wan

lifijalivr. till till- Jlilli »lif wa*
rxaiiiiiii'il very rairliillv l>y tin-
lr>tilrllt a«>l'>taiil |i|iv«irlaii, wllii
liilimt mi t'viili'liri' III ili'-ra'X' nl I III'
iln-t. Till" MHiiitiiiK wliirli iiiii-
tinilril il|i|i<'airil III III- tlllirtiiill.il,
wliiUl till' t<'iii|i<'riitiiii'. wliirli was
nIIII iri'i'iiulaily liit;l>. iiii;;lit have
liri'll ilim to a sort« tliioiit of wliicli
sli<> wa« I'ompiaiiiiin:. Slii' wan
ii'iiiovcil to a small waul in cliuiiro
of M|i<'rial nurses. .Inly .1, tli«
jiatii'iir liail t'i'ascd to vomit,
licni'ial I'omiitiiin ini|ii'ovim.'. Hail
lii'i'ii roiii|ilainin;; of pain in her
rinht jiii'i fc V " , -v i|a' s, ;inil ihtTi-
was a trari' oi ailiiimin in liio
urine, with somi' pun cflls. Slio
I'liiitiiiui'il to roniplain of pain in
till' riirlit loin, so on .Inly 17 slii'
was sent to i|i(> X-iay ili'pait-
int'lit to liavt' till' riylit kiiliii>y
<'\aiiiiiH'(l. 'I'hr M'piirt w.is ic
tiirnt'il : " TIu'ic arc six ^liailow.s
in tilt' Ifft kitlni'v ri'jiion. 'I'lif ri};lit kiilnt'y is normal."

This I'xamination was conliriniMl six ilays latt-r. Sh«> was still complain-
inj: of pain in thr ri>;lit siilf of tlif aliilomi'ii. Thf s]>. jr|.. ,,f nriiii', Hil.'i,
pus lifiiifi lirt'si'iit with lilooil fiii-]iiisi'lis in larcf i|uantitii's, ami also
t'pitlit'lial fasts. On .Inly 24 thf Ifft kiiliii'y was fXfjsfil. It was
full of stoiifs, ami tlifrt' was vfiy littli' sfiiftiiij; lissiif Ifft. its appt'ar
aiiff when fiit opt'n is wt'll shown in thf illustration (I'ii;. I'J). It only
nifasurt'tl ahoiit 2i iiiflifs in If iijith. thf surfai'f was somewhat irit'irular.
hut smooth, ami the oapsulf iionailhf if nt. Thf larjifst stoiif was lyiii}:
in the roniil pelvis aiitl praetieally tiilt>tl it. The smaller sfonfs wt're
seatlerfil throufrhout the siihstatiff of the orjian .\t thf uppi'r inil
there was a small eystie space containiiij;- a roiimlcil slmic. After the
operation she improved iiuiekly. hut even on .ViilmisI ;{ she ~till com-
]ilailied of occasional ]iain in tlie ri^'lit side. .She left on August ITi.

I'"l<i. rj. — .Vtiiiphied left Kidney
coiitaii.iii;.' (iiliwli, which iim-
duced syiiiptiJiiis rfsfiiiMiiif;
those of Acute Appendicitis.

^^S^^^J^?

INI'M KN( i;(H' M'l'KNDIX n\ Aril K AI'.Dn.MKX ii;

III U,|.,l„., »|ir .'.>lh|iliiill<'., n| pain .il.Miu III!' ■■.,iii-r ol ll,. I. II lllil.i.
iiimI \uul M.iiiir I.V.I iiiMl Hi.khf" Tliitv v\M. i.ihI.im..^ .>\.i rlu"
iiift.i. N.ilhint ;il,ii,.iiii,il H.i- -lii.wii ..ii .v.iiiiiii.ii 1,^ i|„. \ ,.,^,_

lltlll III!' s\ ||||)|il|ll'< 'tllxllil'll

III lli> illtclr^till^.iiiiliv^,

(oil ri'liix |)iiiii> ill (jimax-

lit' the aliilniiiiiial \i»(t ra),

Mr. A. Iv .Maylanl nf.t^

to till' <ii ra^iniial traii-.-

tcniicc of jiaiii ill I'i'iial

calciilii^ to till' <i|i|iiiviti'

kidney. an ncciirniici'

well r(<njini>f<| tiir ytaiN

(l-'ig. l:i). In tliis'cax'

tilt re wa> nut dulya tiaii-.-

tcrcncf (it pain, but a >t;itc

of pyrtxia. pitihahly due

ti» a f'-iiipdiary hlnckiiii.'

iif till' rtiial pelvis, wliicli

till- a time prevented the

e>cape (if pus into the

urine. Tlie diseased kidney '"•• '■'• l'i.ii:i:iiiiiii:itir n in.-.. ntntiMii (,f

was tn.i Miiall tn he tVli n''*^ "' ,-'^'^:V';""" V".""" '•"" '"

I'lMM- ■ ,; .MmIuIMIIiiiI \ IV. 111. .\.

•^tllllliull llllll |«ini ICil-.. It. ."^Illiill

iiili'-tiiic unit viiiiiifuriii ii|ip.iiili\,

' '. I.lll>.'r' illto^tillf, ICitlllll. llti'Ml«.

I'. N'ciiMifiina ii|)].(iiilix, rij;lit ..\iii V

Mini tllllC. i;. \(.lT|,llnIlll !l|i|Mllcli\,

li'ith iiviirics niiii till..-. I'. (i,i||
l.hi.lcl.r. .ysfic mid t'lmimnii .Imts,
mill ilu.Ml.'ipuin. H. KmIih'Vs mmi|
uict.Ts. I. (niMri.- nicer f,.\v:iiil>
iMiiliu,' (Mil. 2. <i:i>tric uli.i iiii.l-
\v:iy lictwi'i'ii (iiiiliuc mill |.\|..iic
<'iiil>. :>. (iii~fiii> ulcer lit |>\l.iric

(■'111- I. J.iir^'e i'lt.'Stille iluNVli til
^pl.'llic liexille. ,".. I.iir;:.. iiit.-tllH'

ti.iiii >|ileMic ilcxure te miu.s. .\fiir
.Miuliiril.l

I

When seen at our tirst con-
sultation, had the ease

been one of appeiidi-

eitis. there shduld have

been evidence of swelliiijf

either in the iliac fox'^a

or ill the pelvis. In the

aliseiice of this we did not

ieel jiistilied in recom-

niendiiit,' o|)eration.

Quite recently a female
])atieiit Avas sent in'o the
hospital for acute aj.pem'ieitis. in whom we found a very
movable and painful rif^ht kidney. She had complained of >cv'."
})ain in the right lower abdomen a short time before adiiiis^n,,!.
'i'hero had also bevii a ri.sc of temperature with .•^iekJK•ss. ilic
presence of the swelling, which was very tender, had appean d

-y^^mM^^^:Mrj<jk. .

) i

r I

fli I •

if!

IIS

TFIK ACITK .\I5I)().MI:\

'" '■'"""•..> ll„. .Ii.tun„>is. uhi.l, u;,s n„t n..,.i,.>vd va.U-v l.v )!.(.
n.Tv.M.s a|.,,n.|M.„>in„ of tlu. patient. II,.,-,. tl„. ...Mn'mrlv
■Moval.],. .iKua.l.T. posiliuM. a.ulsl.a,,,. of thr swdlini; sJH.uid
I'avc jriv.'M tl... ,•!„,. as to its nature, as wd| as its ,,rm.„ci. so
soon atl.T tl... I„.ginnit,g of symptoms. It is of r.mnnon
i)<'( iirrciicc.

t. /n/r./ln',l OWo,r//o,i.-Ti,.. su,1,1,.m onset of pain in cases
of aeute obsfnietion .lue to l>an.l>. tui>ts. internal h.Tnia- with
yonntu.jr. loealis<.,i ,|i-iension a.ul visible iKTistalsis. ^vitliout
t.'vcr or sittns of loeaiix.,! inlianunation. usuallv make a elinieal
I'lHnn. ulnel, ,loe, not yvvy eio>ely resenij.le appen.lieit is
■N^ain. 1 ,.. pan. is relieved l,y ].r..>sure. the nuiseles are not
•""sla.itlyn, a. state ot; rigidity, and .listeusio-, somewl.at
<l»i<-|.:iy ensnes. Ther.. is also eon.piete eonstipation and
voinitnij.' is troMl>les(inie.

A raM. winrli ill,,s,n,...s this ..na-ionai .lilli.al.y was ll,., .,1 a l.ov
.IM.I I- pn.yioMsIy M,,,,M.s,.,l ,„ l„v,. I,..,.,, ,,,„„. U,.Mn_ who l,a,i

"""''•■'''"■'' "'.'''"" '■' ""■ ^''-'"""■" '"'■ '".- day., an.l ha.l l„...„ ve n
-I.I.. I ins pan, w.s „, ,1... il.ar l,..s.sa. wu.s ,M,.,va.s..,l l.v p„.ssM,.. ■ I...
';"' " "•'"■"•la'an. ..I -M. , an,! a pais, of i;!n. .V shil,„ . anUus'. ou
I-.-ns.,..„ wa. ,„■..-..,„ ia ,1.<. ,i,h, ,1.,,!.. Tlaae was. howev.'
.-•.>H.Mal p,.r.,als,s. ,.,.,npl..„. ,.,..■„, pa, i,.„. aa.l an aLsen.... ... n.M.li,;

' ' 'T :\ ^V '""'""' " ' ' ^"'^'" '"•-'""• '-".npr-ss...! i.v : . i

;»-;;'"P-l '--l wln..|, pas..,! Inuu ,1... „„,..,...,.. ,, ,h.. as.- „l „. n, ,.
' ' '<■ n.es..,,,,.,,. o, ,!„. s.nall i,,,..,,,,.. ...ar. I, was a,.,a.lM.,r ,o a

"""■■•■•' ■•"-"I"--- ^-'l -•— w- an al.undan.'. ... ..N.; . n

'""X-eal ,.av,.y win.!, I.a.l ...a.l..,l ,,,.rn ,iu s„n,.t,..l loop ,.

ln.s^,n,wn n.,n a l-ahhy n>an and l.as had n„ lather alHlI.nnnal

Wli.;.. n patient is a.lvanee.l in years, the t.-mperat-re is
little, .f at all. elevated : there is early .listens.on and nuu.h
s.ek.H.ss w,tlM,ut a..ythi„g that is .lefinite on examination
of the alKl.Hnen: a state is j.resent vvhieh re.p.ires siu-ieal
■Mte.terenee. unless it is evident tiiat the patient - in a e.mdi-
tion of eollapse and eannot from the nature of the pulse hear
the netvs.ary manipulation. In tin'se eases in the early sta^'es
tlH- yreat ihae teiuhTnos with some rigidity, and th'e rapid
in. se. sho.dd supply the necessary Avarning. An e.xtension
of t h(. area of tenderness (sharp superfieial tenderness) is always
a sc.nous sympton.. especially if there is no great complaint
of pain. '■

Tw,

I

INFI.IKNCK OF .\I'I'I:NI)[\- ON \( ITK AUDOMKN

I I')

'"" l'^'l''<'iv.,.Mtlv|Hil.li>|„.,|' I lMvr,l,.MnlM.,l,aM-. «l,i,.|,
ITov.- tl.at it is |,n»,|,l,. ,.„• a >„r^..„„ „. .ivr an a.vnrat,.

"'"'""•" ''^ *" *'"■ """"•<• «'t til., pat I -ui.-al pnKos .,„ u l„.h

tl"' >y.M,.t..,„s ..'■ ;.., „,:,,. ,,t,a..k .l,.p,.,„|. It i> M( t pnssii,!.. in
'vry ras... i (irthcn, ..,.■, ' |,„M v.rv >tr.„.L'K that th,-
''l'-''atorsho. i,|..Hiravu.,r n ,.>ti,„at,. tl,.. Mai:., ti, u hi.h thr
«liM.a>.. hasal : mv aH . an,.. Jan.i it. nial i,M,>hip t.. sinr...... I-

Hi- parts. This kM.mi..,!;... .a.i 1„.,.,m.i.. ,,t pra.ti.al vali... .mlv

att.M-a ,.,M.s„U.nil,l,.,-xp,.,.i..M,.,..,t .,p,.,.ativ.. w.„.k in ti.is l.ran.i;
with a ..arctui cxaniiriati.m nt th.. app.n.li,.,.. ,.,.„,„v..,i It i.
""t .■n.M...'li t.. >ay that th.. app,.n iix uas ^'anurnu.Mis. u.. nin>t
try t.. ..,„i„. to a ..,..,..|„>i„n in ,yvry .'as., as t,, „|,v it l,:.,.ai„..
^'antrn.n.a... aii.l uh,.,h,.,. (|„. .aii^'..,,.. uas a u.n.'ral .,r hu.ai
pr.i..(.ss.

TlIK TUKATMKNT ..K A.TTi: I M l.A M M All. .N ,., TNI.:

AlTKNDIX.

Th.. a.lvnMta>r..s ,,f ri.ttinu .|„„.( an ilin..^s p,...M.Mi ui.. Mi..h
< an-.i-. as p..,.,ain t.. an a.^ut.. alla.k ,,f app.n.li.itis mak,.
tlif iiiip..rtan,.i- ,,t iimMcliat.. i...|iioval ..Ini.ai.. TUv atta.k is
am.st...l. .li-,..slr.l „f its -....at-st .hum..r>, a p.,.>ihlv tatal
.vsult av..rt...l. and ,i„ w..akn(.ss ,,f ,h,. al.<l,.niinal wall'>l„„.l.i
t.)li.)\v. .M..i.(..,M.,.. no furtlu.r atta.k n....! 1,,. tVar,..! If wr
'••Mil.l st.,p an atla.'k ..t typlmi.! f,.v..r l,v ..x.i.i.m ,,f part
oi till. il..uin I hav.. n.. ,i.,uht th.. ..pciati..!. \v..iil,l h.. , a....ilv
wd..<.nu..|. y..t a n(.gk..t...l atta.k .,f appculi.-iti, j, ni.-rr
(huigi.roiis and (listii.ssiiig tliaii on., of typhoi.i.

The .)p,.i.ati<)ii Avhii.Ji yields th,. nio.t" >at isfa,.t,.i.v H'siilt is
that in u-hirh a ti.inimrary dispJa.TMu.nt ,.f th,. i.,.,tus i. ,|,,n,.
I'lic Avouii.l fail In- saf.'ly cxt..!,,!,.,! to ai.v r...iuir,.,l distaiuc
penults of fh rough isolati,>u ,.f the parts alV,.,.t...l, ..xamina-
tioii of th,. parts an.un,! Avhi,li s|„„ild hr f.-lt . aii,l is „..!
f<.llow,',l hy any uvakiu-ss of th,' al),l,.iuinal wall. Thi-, w.amd
uiay hi' ch^s,.,! iu th,. usual May \vith,)ut ,lraina-... unl,.ss th,.|.,. is
pus in th,. p.'lvis. till- op,.i.atiou In.ing a l...!at,.d .)iic.

It isp,.i.f,.nn,.,lasf..||.,u-sinth,.a,lult, Au in,.isioii is nia.l,-
<m the light si,l,. of the abdomen, nii.hvay lH.tM..,.n the

' h,„nl. V.,1. I.. MI4. p. i:i7<).

^ S.... Haiti,. an.l .n,„.... -S^n^U.O I.isru.,.. of ,1„. Ai,,„.n,lu V.., r.ufunui.. et,-."

'y^.j3iLJ^

120

'I'lIK Acri'K .\IJI)(t.MK\

unibiliriis and ;iiit(ti(ir .-ii|m nor iliai' .-piiic. about 4 iii(lic.> in
loiijitli (Fig. U). 'I'lic iiiiuT lip of tills incision is diawn
(<nvanls the middle line, and the anterior sheath of the recius
iiuiseh' in(i>ed for the full ienjith of the wound. The outer
i-df,'e of the slienth is drawn towards the anterior superioi
iliac s])ine. hy means of two ])airs of artery force])s which are
left on for the ojieration. With the knife the fascial attach-
ments of the muscle to
the sheath are divided,
and the muscle diawn in-
wards. If tiiere is one
of the linea' transversa'
in the part of the muscle
to he displaced, it must
be cut where it joins the
sheath, and a small artery
will usually re(|uire to l)e
caught at this))oint. 'i'he
deep epigastrii- artery is
not Usually seen, beinn
tiiawn inwards whh the
muscle. Some branches
of tlie twelfth intercostal
may be seen, but division

Fig. 1 1.-I,h i>ion f„r Ai.ro.uli.ccto.nv l,v 2,*' ^'"''" ''''". ''" "" ''^""'-
tli<' iHctliod iid\isril l)v Anther. To J-bo j)osti'ri()r layer of
iUu^trute the position- of the skin the sheath, fascia' trans-
iiicisioii With lo-iinl to the rectus ,. ,

iiHisclc: .\. J,in(otiiici.sioii. 1!. Linva '^''''"'«T'«- and subperi-
sciuihiMaris. toneal tissue, and jicii-

toneum are lifted ui) as
<.no layer an.l ,liyi,led vertically f,,,. the whol.. lencrth of
the wound. Nothing is much Mor.se than an attempt to
excise a sloughing ai)i)endi.x through a wound which is of
n.a(le(,uate size. Forceps should be placed on the ed-,.. of
the i)erit.)neum so that manipulation shall not dis])lace it
unnecessarily. Four-inch plugs should now be introduced
and It there is any free llni.l the first should be pas.sed into
the pelvis and the second towai'ds the kidney p„uch As
this method opens the area to be dealt with to the inner side
you can fully ,,rotect the re.st of the jK-ritoneum by gau/e

mm

J

1

3

s

I

4

i

INKI.IKNCK OK .\I'I'KNT)I.\ (>.\ A( ITK AlUX »MI-:N I JI

liackiii^ ' turi' .iiiy -ciircli i- inailc im the apiitiidix. mili» tlif
iiiixliict is aliiady (litTuscd. This is i I iiri|)(>rtaiH('. for
frc(|iiciitly ]iiis is I'mmd under tlic cajmt ca'ci when lifted, or
(■sca])cs tVniii an appendix a^ it^ M'paratii)n is l)eiii^' etVeeted.
altliougli every jireeaution may he taken ))y \vra])]iin<; it in
<^auze as s(»in as possible. In e\cry ea^e eaie inu>t ))e taken to
secure the arteries in the iiieso appendix, ahlmujih in some
instances of uangrenc the vessels may he thromhosed. It is
seldom ])ossihle in the acute cases to j)ut a ligature on the
meso a])pendi.\ to include the whole of it : the thickening
Avhieli liar; taken ])lace a- a result of the inllammat ion does not
permit of this : you must |)lace force})s on the lu •s()-a])i)en(li.\.
beginning at its distal ])art and ap])ly ligatures after the
a])pendix has been cut away Itcyond. 'I'lie se))aration of the
a})}H'ndi.x from the ea'cum can be done with the clamp in the
usual way. hut not in every instance : the coat-sk'eve method
is then em])loyed. a ligature |iut on close to the ea'cal origin,
and the appendix divided between it and the thumb and fore-
finger of the o])erator. which ])revent the cscajie of any -c])tic
material as the division is made.

This ligature is then buried in the wall of the (lecum. and
in eases where su])])urat ion is ])rescnt it is advisable to use
three tiers itiiiuous l,eiid)ert sutures; a single line of

enclosing su y give, and a fa'cal fistula form. Where there

.'las ))een no .ape of pus from the ai)pendix. the area from
which the ap])endix has 1)een removed should l»e cleansed with
saline and any excess of tiuid removed l)v the introduction of
a ))lug into the bottom of the ])elvis. Where there has evidently
))een a localised su])puration aljout the ajtju'ndix. and it is
tlioiigiit ))ossibie to close the Avoimd without drainage I have
thought the a])])lieation of jteroxide of hydrogen (I.") vols,)
useful as a means of destroying se))tic material which may still
remain. The womid is sutured in hiyers from behind forwards,
in the Usual manner. If a drainage tul)e is ])laccd in tTie
woinid it should lie biought out at the lower end and be of
adecpiate size.

If the (hsease has been ])rogressing for more than forty-eight
I'ours and there are no signs of localisation of tlie septic
inflammation, an incision through tlie rectus muscle is preferred
by many. Jn this the muscle is divided about tlie middle of

122

TMK ACITK AI'.DOMKN

1-.^

its l(i\M r M'Miiiciit and llic tun lialvo Mparalcd. I iliink iiiv-
sflf tlial it is hi'ttcr to (lit di aiily t liidimli the miiimIc parallel
to its liltrcs latlur than roll t' ni away troni the si'lcctcd
lini'. so often it is found that tluy refuse to unite when thev
eonie to^^ntlier again aftetwai'ds. in tlii> method the oiniator
must tie several vessels in the muxle >ul)-tanee and .-eeufe the
deeji e|)iga>trie ves>els in the lower pait of Die wound, dividim:
them In'tween lij:atures where tliey cross the line of the incision,
in the-e late eases it is well to pa-- a huLie |>lug into the ]»elvis
so that it may soak up the liuid MJiicli ha> gra\itati'd there :
you will llnis j.ret lid of excess of lluid without wa>ting any tinu'.
'I'tiis plug should \)v changed during the course of the o|)eratiou ;
luit it is a. mistake to wash out the ]ielvis with lluid of any
kind. a.s the mariipulation jxrformed will prol»a!>ly tend to
ililTusc the septic mati'rial. I)reaking down defensive ))arriers
which are already doing good work. 'I"l,e opeiation should ]>v
IH'Hormed (piickly on delinite lines and with a light touch.
Jn tlu'.se cases of moie extended mischief drainage should he
])rovi(led. hut it is not often tiiat a tube is iciniired el>e\vliere
than in the ])elvis. If the renal pouch is involved, then a tube
pasx'd into ii may make for greater secuiity. and this may he
])assed in some instances through a separate inci>ion in the loin ;
hut the insertion of multiple tubes is not advised.

It is good that you should have a standard of what is tin-
l)est to l)e done in cases of this kind where the septie intlanima-
tion is becoming generalised. Hemember tliat the danger to
the patient is due to absorption of toxins by the lymi)liatics
of the affected part of the peritoneum, and if you can diminish
tile amount of poison whieh is there or oidy check its iiu'reaso
you will give the forces on whieh you must ultimately rely
to save the ])atient a. chanee of coping with the situation.
-Many ])atients liave died as a result of too much surgerv —
the operation has been prolonged beyond endurance because
it lias been felt necessary to take away the apj)endix. and that
ajipcnibx has jxissibly l)een very adherent, awkwardly ]»laccd.
and the bleeding difficult to arrest, or the patient stout and
intolerant of the aiui'sthetie. and perhaps tiie operator short -
lianded. 'i'lie bruising and distur})anee of parts lias caused
an increased local absor])tion wliicli has been more than the
already exhausted individual could withstand, and the heart

^J*k

iNrr.ri:N( i: ok aim'kndix on \( itk aijdo.mkn il';$

has failed. 'I'licic air many ot' llic late caMv- wiiich will
rc-]iiiii(i to -mi^iical t rcatiiiciil it' the intra aixloniinal tt ii>inii is
relaxed l)y the int niduet ion of a drainage tiilie thniiijih an
in(i>i(>n (if moderate >i/.e and no attempt i> made to lemoxc
the a))|)endi\. or jiive a ;.'eneral ana'-thet ie. The u>e of rectal
infn-ion of sterili-ed saline and tiie Kou ler \. sition (l-'i^'- IJ)
slioiild he comlt neil With this treatment.

In later eases the iieritoneiim may he eotucrted nito an
ah-cfs- cavity eontainin;.' many |)ints of )ius. and sometimes
recovery is enecled when the aid of the sur<;eon has heen
refused, for the ])iis is di.sehargcd hy the howel.

I have known mo-t unfortunate results to follow inteiference
wIr'Ii the (Use is settlinji down, hut iias not hecome (^uiet ;
therefore I am strongly against operation under' >uch circiim-
.stance-. If the case is first seen after four or live days have
ela])sed. the inllammation is localised, and the general condition
satisfactory, do not interfere unless ohiiged. It is the spreading
su])pur'ation tl;at cause^ an.xiety.

Occasionally the colla])se resulting fiom tiie attack is so
extreme that o|)eration is oidy ]tossihle after intr-iiv«'n(>\is
infusion of stciijixd >aline.

.Mr. ('. i'. Childe iias written an interesting ])a|ier ' on the
(|Ue.^t:on of tiie ])o-ition of the incision in o])er'a.tions for' ai \ite
conditions of the alxloiiien. and it is well Mdrth ])eiusal l>y all
sirrgeoiis. Ill this he ])oints out that nearly all the diseases for
which the surgeon is leipiired to operate, which cau^e the acute
al)domeii. have their origin hetween two imaginary liri('>. the
one on the K f t drawn fr'om tlu' seventh cartilage, an inch to
the left of the sternum, to I'oujjarts kgament ; the one on the
right dr-awri from the antei-ior- su])er'ior s])ine ])i'i])en(li(ularly
ui)\\ arils to the lower' l)or'dei' of the tiiorax. The incision which
he reeommeiitls in cases wlier'e the ahdominal condition is
ol)>eur'e is one which is ])laced midway l)ctween these lines.
This would, however, come directly over the r'ectus mu-cle,
the outer margin of which (the linca semilunaris) is fomid at
the junction of tlie imier three-fifths with the o\iter two lifths
of a line fr'oni tlie anterior supei'ior s])ine to the umh licus.
The incision through the rectus is not a had one in acute

' Tin' .Vii'ii nf •• .\ruii' .Mhliiiiiiiml ( .ii]|lii.\
l.iUicet. VMU. v., I. I.. i>. VM\.

:i\U\ tll(

lliri- 111! nf IlKl.lltU'i

124

'INK .\( ri'K AIJDO.MKN

n\'

ill

alMldiiiiiial ciiM's. anil I have ofJni hmmI it : but tlicrc iiiu>l Ik-
a clear uiulcistandiiij^ of tlif liix' wliiili comcsjjoikIs to tlu'
«'(lj^r of tlif imiM-lc. if the ojKTator wislics to taki' tlia'.. Tlu'
eoiulitions wliicli iiio-<t frccjiiciitly ])ro(lii(c tlir acute abdomen
viiry soiKvwiiat at dilTcrcnt a^'es l)ut takinj: an uviTa<,'c of
ii lar^'e iiuihImt of ])atients. a diajiiain may l)c drawn which
expresses fairly well these ])o>itions and the fre(|uency of their
occurrence by means of sliadin<i (^<'t' l''i". I'*)-

l''lii. I.J. Tlie scijii-iccuiiiliciit iio>itiHii :i(l\is('il in Acutf Aljdmiiinul
coiuiitioiis, known :is "'I'ln' l-'i^wlcr l'o-iti(,n."

In Fitz's ta))le of acute intestinal obstructions no less than
<i7 per cent. Iiad tiu'ir origin in the right iliac fossa.

It is now customary to i)lace tlu- patient in bed in a, sitting
attitude — •• the Fowler position "" (Fig. 1.5). The object of (his
is to encourage the gravitation of fluids towards the pelvis, thus
limiting the infection to a j)art where the local resistance
is high and dniinage feasible. The ])ressure on any barriers
of defence is also lessened. TJie maintenance of the ])osition
may be facilitated by the fixation of a bolster, padded block,
or stretcher across the bed. just below the level of the buttocks.
It i- k(pt in place by straps or bandages pa>sing to the

iv :.. 'i i

INFLrKXCH OK AIM'KXDIX OX MVTV: ARDOMEX \2r,

^

licad of tlic 1)1(1 on fiuli >i(le. In any cum- in wliicli the
]iaficiit"> cDiKlition is not ^ood at tiic coinjjiction of tlic opera-
tion, a pint of warm saline, eontaininj.; an ounce of l)ian(ly.
>lio\iltl be administei-ft! by tlio rectum before lie leaves the
table. .\s a routine, after tlie patient is arianj^ed in bed. the
continuous in>tillation of saline is con\meneed. .\ p( liorated
])eAvter tube or .lacfpK's" catheter is introduced into the icctiitn ;
the end of this is attiU'hed bv means of rublxT tubinj^ to

<i^

l-'pi. Hi. — Siuijilo Aiiparutiis usoil fur tlic < ■ciiitin\ioiis .\ihuiiii>tratiijii
ui FhiiiU I'll- ikIiiiii.

a reservoir containing the lluid. kept at a, temperature f)f
105 . Till- ilow is controlled by a screw-clamp on the tube.
Tiu- vessel should l)e a])out J foot above the level of the
rectum (Fig. l'>). Other more elaborate a])paratus can bi-
obtained-

Sometimes the saline is not retained. This may be due to a
too rapid inflow of the lluiil. or to its being at the wrong
tem])erature. In other eases the lower i)owel must be eU-ared
out with a sim))le enema before toleration to the inflow is
etstabtisiieii. if this melliod proM> iiapradiculWe. >abou-

I2U

THK ACITK AHDO.MKX

"•<■'<« <l. At lu.ws the .•,.,.li„,„..l Hon- .,f .,,|i„. i„,„ ,1...

a->''..w:';; l;r"h!":::l..;;; Tt' """ -"•"" --- «•- ••••

'■'!•>••'•■ -ilia u.n.u,i. tiu. ann.!o. axnJv ;:;':!:: ;;;:

; .li<■|.n,J.„y■•p..,,oMisM^•'s..„,.. .,,HioMfn,n,i, .nav
xp-h;,l afUT ana,, of a f,.w hours. I,,., if , ,.oll,,ps,. is .l,. o

It must not iK.-forgotf.a that th. ulti.Mat. .-ours, of th.
-. .s g,vatly .nMucncod by attention to .K,ails in tl... treat-
nu'iit alter ()))i'ration.

In stout patients M-I,er<. the al„h.„,ina! wall is verv fhiek
;'s,.ee.ally ,t rapul operation is ealle.l for (au.l it us.^.l!^ '
>t the surgeon ,s sh.^rt-han.led. the incMsion is betfr p aee i
l-ugh the hnea semilunaris. It „,ay bo more liable t
-:•'- I'^ter but this eoMsidc.ration nu.s, „ot be allowe t"
; e is'";::' ^'•' ^'^^'^'^^'^"7 ^--f™- <'f tlu. operatiL
;P'.to. M,| gam a sueeess mIkm. th,. slower one will fail

h lo,^ o^anynK.>sionsh,>ul.lbeonewhiehMiiia,hnit
ii.uKi or flic operator.

Tbe pelvie organs in the female shoul.l ahvavs b.- exan.ine.l
J)ra.nage tubes n,ay be ren.ove.l in two or tiu.e ,lavs un ■':
IH' .bschargeat tins tim,. continues profuse or the tempera re
l.as not eonu. down. At any time it is better to X^
ongmal tubes rather than put smaller ones i„

It .sm. usually a<lyisable to give anytiung by the mouth in
'^< r'^ '"!"'^ "V"'- "IX'-'ation; the absorption of saline
t.. he e,reulat,onreh,.ves the sensation of thirs, .,,,M,,,.,,,,:

''"•'"'"-' -"'■•■■'Pi.lit.v of exeretion of t...xiepro,b.ets (,

I! I

IM'MKXC i: ol' AIM'KNDIX ON .\( ITK AIJlx ».MI:N 1-7

I

llii- iicumil lli.ic i> no (I.Milit (li.it \Ui- >Ic,Mly iiitrn.lu.iinii uC
lliiiil into ,lic system by one iiicaiis ,,|- iuiolli.T i> i,t ^^na)
value alter Dpenitidii in eases of pi lildiiilis.

.\t tliis sta<,'e the (|iiesli()ti of u\^ jn^ aii " aiiti tn\ic vriiiiii ""
ari-es : the infective jnoeess in hki^i ,•■,.,> nl' a)i|ieii.li.iii~ i>
'iiietull,el,aeillnse(,li : an. I an "aiiti • Miiirn 1.. tl.i^ or<.'aniMn
lias heel, |.re|)an .1. I have employed it in a nnmliei .,t ea^'^.
hut eamict - y '.ha, it appeared to mat<Tiail\ alter 1 he e,,ui>e
(it the (lipase v.lien cdmiiariMMi is made uitii iiiMaiieo not -o
tivated. The serum should be injected into a j.eetoral or
gluteal muscle; a dose of lM» e.,.. i> ,/n n innncdiatelv after
the operation, and this may he rejuated at intervals ,,f twenty-
four hours for 1\v(. or three days, .h.int ])ains and llc.tini,'
rashes not infrcipiently f.)llow this administration. It i. well
to have a vaccine i)repared from tli<- fluid removed at the
operation, for it is often of value when the pro^M(-s of the case
is not as satisfactory as could he Mi>hed. Kspecially when
(he temi.eratiire keeps a!)ove normal, althouizh there is'm, p„s
pent u]. anywhere, and discharf:;e from the wound yoe> ,„,
without evident cause.

For the relief of the pain and discomfort still pn sent after
the operation an injection of morphine may he f;iven. if a jrood
night's rest is not otherwise to he (•])tained : hut on account
of its action ..n the howel the dose should not he rejxated.

After every operation .some vomit in<.; is to he expected, and
for the first tw. ty-four to thirty-six hours no definite treat-
ment is called for to c<mi1)at it ; if. howcvii'. it continues
longer, becomes more fre(pient or offensive, an atti'inpt to
eheck it must be made. The sliirhter eases mav be stopj.ed
by the administration of a dose of ,,'_, gr. cocaiiK- in an ounc
of water at intervals of an hour : sometimes minim <loses of
tincture of iodine are successful. If these meaMUCs fail, and
the ])atient is much distress..!, the stomach should be wa-hed
out with dilute sodium bicarbonate solution : this will at anv
rate give rest for sonu" hours iuul ])rol)abIy allow of the ])rope"r
administration of a purgative, which will materiallv henefit
the condition.

in till' liH.n }.ersistent cases the progn.^sis become, verv
grave, as either a genera! toNimiia, -vvouilay irit.Min.ii
obstruction or acute dilatation of the stomach is j.roent.

i :

m

i>

w

I. I

I

us

THK .\( ITK .\I5|)().MK\

An iillrinpf to ol)tiiiii an iiction :,( !|„. UnwvU -lioiiM !..• tniidc
on the sicuikI <|,iy ful|.,«iii^ tli.' ..|,.rii(iuii. I u^iully yivc a
'.i to .-. nv. (\nM- of caloni.l, f,,||ow,.,| afl.T four lioins l,v '-,i^.l..M•^
of inaKnoiiim >iil|.lialc <.r ..(Ikt salii„> |MirL'ali\r at huiii'
intervals till an action is oi)taiii(<i : in oh^tinalc cax - I liavc
found a ;,. nr. of ..latiTJn v.t.v u^ful, tlir valur ,.f wh;.!, was
first (l..nioiistrat.-.l to nic l.y Dr. .Ii.Iim Han.l.l. '|'|,r diet for
the lirst few days should he fluid in rliaractcr ; if no advcr^.-
syni|)toni> arc present hy the third or fourth day. Muall amounts
of ehieken ereain ami li-h may he ^-iven. and" it the end of a
week the jjatient wdl he ,,n practically a full diet, if it is
fancied.

Meteorism. sometimes very intense, associated with a feeling
of ureat abdominal <liscomfort. ai)](cars in m,,,,,. ,.a.,.J^
halicatinji as it does a paralysis of the mu-cular coat- of the
intestine, its piTsistence will aJvvays uive eau-e for an.\i<tv; a
tiir])entine enema (V—VJ turp.'nline in v^ of fua.'iacmuUion)
or the action of one of the 'bovernentioiied purgatives mav
relieve i.- condition, [f these fail. an<l the ))a>sage ..f a long
rubber ...a! tube ji-oves e(|ually inelfectivc. tlnve or four
subcutaneous injections of escrine salicylate (,,'„, gr.) mav be
given, though in my exjxrience it is of small value in tho^c
obstinate eases which are due to more or less comjilctc intes.
tnial stasi>. when the necessity of a secon<l operation must
be considered, i'ituitary extract is now used ))y many (I c.c.).
re])eate(l hourly for three orfour doses. If the obstruction is
eaused by an intense local ))erit onitis lift le can be gained by sucli
interference ; in eases where it is due to mechanical kinking
or strangulation of flu bowel, operation will afford relief.

The wound will re((uire at least a daily change of sterile drv
gauze for some time : if the discharge is" copious and olfensjve.
gauze soaked in 1 in KldO lysol or in I in so carbolic is to i)e
l)referred. Any local tension must ;,■! once be relieved by the
removal of skin sutures. Cellulitis or sloughing of the abdominal
wall mayreciuire more radical measures such as incisions and
the frequent application of hot dressings, but if the wound has
been well guarded during the operation the local infection will
be slight if any.

Ali degrees of fanal fistula may develoj) in the wound '

' .S.i- • Jj niilM-s uf lili; Al>|ll'll(ii.\, -Jud I'll.. 1>. :.'SJ.

iiJUg:«M«;iafaBaBar>.%jiMB3Mi^

:^ l'UH.iUBRPi?»Hfvy:3i-<l2^r«aS

■u/.'!^,l-^..h^- 9t:''

lM'LLKN(K(,F.Mr|.;M,|x..\A,, IKUUX.MKX ,0,,
from ,lM- M....„Hl nr th.nl .lav ,n ,),„ ,.,^,„th ; .Ihv ,n,.y Im- .lu.

".Wl ulnn. Hu,.|v,.,| ,„ ,1„. inlla.nmutin... TIh.v t..,ul to
>l."n.a,u..M. I,..a|„„,npnu.,„.allyall..a-,.; ,,....1,.', . ,e

'■ ^•M>. V,ol..M, ,.U..„„« sh.,ul..M,.. aVO.,l..,l ; .lu.cI.V.,-

•i;;^ HUM 1... ,n.,|„..,„ly ..|.aMu,.|. and an ..utM,!. pa.l of
<•'» '-'V ...I.Mir ai:.| provr an ..■onomy.

a';r:n:'- .''''^'■''''■'"'•^••- ^-'^'-- -«- -f toxemia
..>,ou ,.f ,1... abdon...... \Va.|,i,.« ..,., ..f tl,.- -.o„,a,l, witi,

u . S,,.,uld .,.,,.,.„„„.. fa,,. „,.. Hdm,ni>„at,on of a i.,.;t
ot iuola.M> or ,.,.„„non tnarl... ...ya,,, will not infivm... ,tlv
m.n . It ,. a,lv,>al,l,. to prot.Ht thr ..kin l.v „wans of „int
;n.nt, ..f.f .... ,,,,.. .o:ntn..n,,va;...n..o.:i:':^

A MMiou> amount of ,.aul>a.. w.ak.u.s loading, to rani.l
P»lso. lMvathl,.>Mn.>s. and dro,,>y of tl.. I.gs n.^v d,-

.1 uad> >pok..n ; ,t ,■,..,„„■.., nuT^Hi.. trratMH.ut w,th di-Mtali.
>t.yeiMnn.., an.l otl...,- .anlia,. stimulant, .li..,, .,,.. an. n re ul

cTI \;.;,1 '■■ ""■" '^■'"•" ""• ^^•'"""^ '•'--">■ - -' -l"'t) l.a.s

thf 'n/'^ ?;;"■ '" ''''''^''^^'"" "^ ^'"^ ^"""■^"^' - - '•'""plication
iH- state of tl... patu.nt n>ay j^iv. w..il-tou.ul,.d ..aus. f.r alarm

mproyonu-nt follows .astn. lavag.. pos„ion, ..u. ^a e "'

1 .as^UH, out .s not toL.^uod. it is .on^tinu-s possiblc^^;

be gum a a.^.- .p.ant.ty ot Avarm wat.-r and in.'.uc-d to roject

Ici^uion "iVr "''"'' ' ''''' '-''' ''' ""^y--'^' ^^'-thC

uie patient did this most successfully.' ^

A..\.

' •''^••^ l.'t'ir/'f. V ,1. I., lOM, March L'l.

K

if^i

130

rilK .\( ITK AlJl)(».Mi;.\

'ill

!.()(. \MSKI) sri'l'l i: \l ION.

Al'TKNIlK I l.AI! Allsi K>s.

LociiliM'il Nii|i|Miiiiti(iii i-, iitiii'li iiioif luiiimun t iiiiii i- uincr.illv
hclii'vnl ; iiilliiiiiiiiatiuii <.t llic a|.|iiriili\. Imiiil: nf a -ciitic
nntiirc, ficfuicnlly Iriniiiiiilr^ in Mi|i|Mirali>>ii. .mil mii' nf the
<liiiigfis i)t 111,, (lix'ji-c i> tin- Liti'iit ihaiarti T wliicli mhih- of
till! al>^(c»is a»imit'. Sormtiinc-. pn-. |, tniiml alidtit an
ai>|»iii(li\ lony aftir the tcniitt ratmr ha- IxKinic nniinal ami
all pain and f('n<lciii<»s ^onf. .\> a rule liuwcvci, x.nir
tliitkcning may l)c felt in tli<- ivui.m ui the apinndix or an
ubnorinal ic>i-tancc to |)ii'»uif. If an atiaikof a]iiMii(li<iii>
of more than avcra^'c x'vciity ha> hciii cximi i,nrf»l. and a
N\\ -llinn has formed in the diac fo»a. llicic i^ n-ually >U|i|iura
tion ]>ic>cnt. lint a .-.uddcn fall in thr 1.in|itiatinr. wlncji had
continufd liii.di. and improvement in the ^ieneial eondilion.
may indicate the e-eajte of the ]»us into the Ixiwel,

111 other tasos, after the temperatnie lia> Iteeonie normal.
or almost nctrmal. it rises aj^ain. an<l with that there i> an
increase in the size and Iendernes> of my intlamniatoiy ma>N.
the position of which varii-s with that of the indixidwai appendix.
There are localised sU]ipuralions second, ny to di-ea-e uf the
ajipeiidix which are foimd in other jiart- of (he hody, but tlie-e
are treated of elseMhcre. If. however, tlie local sijins of
jibseess are not found in the iliac f(i~>a or loin, a vaginal or
rectal examination shoidd be made (Kiy. IT).

The rij,'idity of tJie lowi'r i)art of the rijiht icclu- u-ually
|)ersists. but no longer conceals the .-Mcllinir beneath : iialeed.
the mn-cle is often jiushed forward. Thi> swelling is tender,
especially where most ])rominent, but lluetuation is rarely found
unless tin- case has gone so far that the abdominal Widl is being
penetrated or the purulent collection umisuallv large. Per-
cussion over it shows a change from the normal, and where tlie
parietal peritoneum has b come adherent the note is evidi^ntly
dull; should the abscess contain gas then hyju'r-resoiianee
will be found, witli some dulncss varyiii',^ M'ith the pusitiou of
the patient.

When the absces.^; lias been ])ermitted to penetrate the
abdominal wall, there Mill be redin^ss an<l n.<|enia of the skin.

K<»( .\I,Im;i) sirpi'i u\ti,,\

1.11

■I " •!. w III ri

'I' ■,. rr.if

.ll).'C ,|/.,.

r..!;:'rtrr:; " "•'-->

.^^":'i;:;:;:!!;:;;:\;;;;:::j\:':,r'';-r'^^^ '-■ - -•

<li'W..,M.soi'-|.j,,,|i.,,^,„; "■ "" '"'"-Pi'.-luill, rl„
. '" "'«• «liagi.u>is „f M.MH. .a-.., ,, 1,1 1 ,,„„„ ,

A pHHl in>.a,„... of „ ,..„.,,...,„ .;.| „!„..,.. „^

;'"•■'' " «•'■* «l"li'"lt .„ .ll.i;;,MK,- „>
♦"<• .1 luri^ tim.. ,t ^VM> .oiir.al.-.l j,
sl.UWM l,y U .HM, .,.,.„ „„|. I,, \\,|,,.„
Mijkcr.

Tlio,.vt,ent a..unM.a.n...lKi,|.,i-':i, ,.,„..

I I ainU,.vcn.sh in .Ium... I!m.,s. ainl .1.,, .,.„.
'I'tior. 1.....;,,,... ,voi,.. ,n Autfiis,. n,,.,,. „ .>
"" vom,t„.KHi..l nol.Mul ,.u,„. iH.f a .'..,,,.,'.1
w..ak.|..,s wul. ...V..,, J„, s,..k.-r. uh,. u.;,

l.n- .•a.v.ully ,HMs...l. ,,„1 „, s.,„..„.l,.., \

MV..||.„u uas ,..,„ui l,v |,„„ i„ „„, 1,,^^

"''•'•""•"• Tli- t.v.., WHS „l a h.T,,.-u,.,.

uiHlm^l,, MV..UU wMh lo„ „, .|..,|. .„..■„„., r

>I.H.ii.ll,a.itw,. M,u,|.ua.lark,of|..v.., ,1,..

iMst wlK.u 7 ,v,..r,s „l a«,. an.i ,1... m ,,.1

-^eveu voars Ik-Ioi.. tl,„ ,,,,.^,.,11 ,||n,.,. Tli,.
IHTiods «r,e ,,aii.lu| ati.l „„.;;„lar. („.
X'I'HMul..., 17. tl... low.T al,d„„,.,. ,,, J

M.nu.what tull.r than uoi.nal, ..•,d .1...... „ 1

>.-M,a,u.,,to,M,.,ssiue. <>..J„.^■„ssM,.MH.^,;v
"'v.k,.dl.v dull area wa. i„v..ni. \,n, u.nl,.',

I'-lownpartolth.. l..|tm.,us,L,. no,.. „..
.ympamli,. a. ,f iron, a uaM.,..,. al,.,,,.. . „ „ ., „ , , ,
npiMT l„„„s of ,Ji.- sHvIl,,,. „-.-ic lui.lv .1, li, I , "''■'■' '""' ""•

.■lo.hu,thay..||ow..s|, „h>...,u..ml,ran.. J , , '"'^ '" "^ ''>' ^

wo. ,Le s,«„.o.d ,i...„... wh...h „;::;" c ri:"' ■ ''';"^ -'^^.u-a..!.

Muall .ntcstmos were displaced upward, , d , ,1 . ^"'""""- ""^'
ovaries, bladder, etc.. were .pute d .„ h , '" '"• ""• '"•"-•
eoneealed. lueisiou «uve re ease o a K, ' '"' ''^'l'"'"*'^ ^^^ '^<^-
withoM, eharaclenMK-odou,. V d m.t / n!] '''"*'""'" "' -"""^^ !'"^

A sinus formed and would no, heal m 1 ,!' '^^^'I^

I ne aiipendii waa turned
K -2

132

THE ACUTE ABDOMEN

luiiiid an (•niaigod and cy.stic o\ ;ii j , and was much tliii'kened, sliictured,
and adLfU'nl. >li<; made a >alisla<'toiy lecoveiy.

\\'Ih-m tlioc iil)stc'»(.'s arc watclii'd fioiii tlif (■(imiiiciii'i'mfiit
tlii'ic is a^ a. rule Jittio ditliculty in asciibiiig tliciu to tlioir

riglit soiirci' (Fiu'. JS).
lUit wlifii siTiv for the
liivt time mhuc days
at'UT the unset of ail
illiK'ss tlierc are otiier
conditions Aviiieh must
l»c rcmcndxii'd whicli
may cause similar ap-
pearances. Of tlu'se
may be mentioneil —
(I) Pyo-salpinx ; (2) in-
llamed or sujjpuratini.'
ovarian cyst ; (li) acute
l)yo - nt'j)iirosis ; (4)
tul)ereulo>i> of the pi-ri-
loncum ; (5) actino-
mycosis ; (()) abscess
secondary to malignant
disease of the bowel ;
(7) mahgnant disease of
tlie ca'cum or ascend-
ing colon.

In I'yo-ueplirosis the
tumour is in the right
loin and is distinctly
outlined. It has pro-
jected gradually from
the kidney region,
mo\es on del']) iu-pira-
tion. Occasionallv a

. Is. l)i;i^r:nii iiT till' imtlis nf I'ciit.iiniil
liifeitiiiM in ri'liitimi tn .\]i]iiTi(l!i'iti:-. Tin'
])riniiiiT i'liiiii i~ in tlic ii;;lit iliiir f(i>Mi.
1. l!ij.'lit->i(l('il ^iiliiliiii !ii;i;.'iiiiitic iiliMi->-.

'J. l,'i,L'llt->illc<l MlMll'l'Mtic ;ill>l'f>S, .').

l!i;^lit-si(lr(l :iiiti'-i('li;il iil)sri->. 1. I.ilt-
>i(lcil antr-n'niil iili-ic--. •'). I'clNic
iiliMC'>>. r>, AliMi>- in till' it'll ilinc l(i>s;i.
7. I .I'll ->iili(i snliili:i|iliniL'niiiti(' m1m('>s.
llitwrcn I ;iri(i 7. ii lilt-^iilcd >ulihi'l>;inc
iilis(i'>s niii\ I'c Iniinii. Ill twtcn <i imil 7,
a Mil'>|il('nir iil'M'o^ may urcur. Minni
" Sur;.'nal 1 lix'aMMil' tlir .Vi'i'i iidiN, cti'., '
•Jnd .'(i.)

calculus can be .seen
witli tlu' X-rays. There may have been renal colic with pus
in the urine.

luflainc<l or Suppurating Ovarian Cyst. — Tlie change in
ll.e cyst may arise in various ways, freipicntly from twisied
pedicle, and is dillicult to tliagnose when seen after a few (.lays'

I.OCALLSKD SITI'ITHATION ix]

ill.u->..>l,ouldtiu-,y>tl..-rM.i,vIyiHlra,M.Ivir. I„ .l,e In.^inni,,..
..f ti.e .lln..» a Mvlling nm.l.l hr f-nuHl .,f a >i/.,. t,.., la,-'., inv
any nM-..i.t iiilla.nruatciy .u.ulitini, t,, |,avc rcach..| • lat.-r

It may still retail, it. .Irfinlt ulinc WMh-.v ,t i. al.,.v.. t|„.

IH'lvir l.n.n it ha. pn,l,:,],ly Invn vvrn.^u\^,.,[ l,,,„,,, ,,„. ,,„„,,
<it the iiitlainiiiatioii.

•'il'y...>ali)i.,xtl...,visatuiHonr|.rr-,.m ..„ vauinal .xarnina.
lioM. i....s,l,|y on iH.tl, M.!..>. thou.Ji th.. >i.|,. „-|,i..|, i. ,.a„.in,r
the tn.ul.l.. IS ti,r nu.iv tciulrr. Tl.nv mav !„■ a l,i,t..iv ni
.lysi.u-im,TlM,.a. in,.n,.iTha,i:ia. I.a, ka.'lu.s. vaginal .lisrhanM.
aiu ,M,>siI,|y f,.v,.nsl, attarks. 1 |,„,, i,„.„,,, ,, ,,„),.,„ ,.„,,,i,[;,^;
|u..l trcatcl t,.r tiihrniilosis wlirn Miir..|ii,<r tinn. thi. .li.,...,-
I)ct()rc the pyo-saijiiiix niptincd.

-\l)sccss srcondaiy l<i iiiali-iiant di-ia.r .,f lli.. I„.u,.| ,,1 ,v l„.
•I"<' t.. the pvin^ May r.f a stcTcnn,! iih.,.,'. mIm,!, h,,^ l„n.i,.,|
srcoiularily to a .•arciiinina of tl,,. low,,- part ui ih.. la,-..
iMtcstiiu- or nvt.ini. It is a. very ...rin... .oinpli.ati .1, an.! iifa
St.. lit sni.j.vt inmht 1... nii>tak,Mi at it><-oin.ncn..,.,ii..nt tor ui
attack ..t apiK-n.li.-iti>. Th.-r,. k UMiallv a hiMorv -f ..l.^trn...
t.on. ..I.stinatr .•..nMi,.ati..n. or .liarr',.,.a t.,r >oin," tin,,. \,ri:r-o
tlK' e..nipli..itmn sIi.av. „n th,- ri,-l,t si.lc of tl„. alMhinu'i.

Oc.asionallya (Innvth in ihcCavuin nn.hT.',.,.. a .'ha .<r,.
l.ossil,|y from n,.,ro>i> ,.f ti>.M,.. an.i s„p,,nratioii lak.- ,,lHrr
■>.-,.nn,l It : it is a v.-ry .li^.v.^in^ .■.unpli.-ation. h.van',- an
'"*'<"'|'>I'' *aval fistnia forms aft,.r tl„. pns is ,.va,nat,,l Ur,,,
a^'aii. M IS possil,!,. ,0 ^r,., a history .,f ilhu-.s u-itl, th,. p,v>,,i,v
(.t a locahscl swdhnu lu'toiv .•,,inp!ainl wa. ina.l,. ,,f i|„. ,„oro
acTtc cm.litioii.

Th,. ivsoml.laiuv hctw,'.-,, an app,M,.|ix al, .■,■>. an.l a fumonr
'"av 1,.. v..ry .■Iom-. .\ „,.,. .,,,„ ..ith Dr. Arthur Broun,- is
a u,)<i(l cxainpi,' of (his ,iitli,iilty.

A nun. .,1 :,n. s..„n au.l ,„vv„M,.h l„.ulil,y. I.a.l an al ta,-k „t al-h-nnnal

I- " ^-<i voininn. ,iv.. .....Us i...„;r... T,„. ,,;,„;:'' :::: ,

r.«iu ihu.. I..ssa. F..r at,.,.,, ,1„ ..,.,. ,'.i,.,in,„. mv.-II,,,. , ". !

...,•..,. ,..,...:■ ..,, ,,,..ss,„.., an,l ,,a,n„.l „l,..n h.. was nL.,v„„^ al,..,„
I., ha.l n.., ...1, ,11 ,.n.,„.l, ,.. ,.„,, al,...,., h,.,- ,„ l,...l. a,„l ., , |v

f :";''""" V"i ""","■ ■''"■"• ^^■•■^^ ^' ''-"I --•11-^- ""• — '» a la ' .
St Mil. r,.„„.l...l „n,l,n.. „„ ,1... ,,.!„ si.l.. .,t .1,.. al-.l,„a,.„. I,..,w..,.n th..

"..>.>h..„s an,l annai.n s„,.,.,„.rs, ,l„ll ..„ ,...,,.,„.„,„. v, v ,..,,.1..,

"" ""."""! 'l'"-""^'i">' •■""1 ....,val. „ ,1... .I..,.,,,... ,,,„u 1, , .:

;""•'."' ^""'' "• ' '"■•■ "'^"U'M ..1 ,1„. „.,.,„s nn,>,l,.. ua. a.ih..,..,,' , ,

the abdommrd wall. Th,. ....uporatn... uas n,.r,nal. .\1,., ,d ..

.V J^p-^'m.

' r"

if!

r

m..

134

TTIE ACUTE ABDOMEN

monlhs l)oforo lie had liad an attack of pain on the rij;ht side of the
abdomen l>ut it was not of lonj: duration, and no nwcliin;: had lioon
noticed. 'J'he operation was done in two Mtajres — (1) incision ot al>scess ;
(2) removal of a]ipendi.\ twelve days later, '{"lie ai>i)endix, which was
larjie with very tliii'k walls, was adli<Ment to the pari<'tal peritoneum
under the rijrht rectus, 'i'lit; ahdoininal wall was very thick from lat
dojiosit and the muscles and fasciic very much dei;enerated.

Ill these eases the jnevion^ history is very iiiiiiortaiit. and as
a rule a new liiowth is more jiroiiiiiieiit. elearly oiitliii(>(l. and
less tender. Still the diagnosis will oeeasionally be very
dilTieult in fat ])atients.

I have els( where' jiuhlished the aeeouiit of a case of largo
C'olloitl (Irow I of the Ascending Colon

in which there had been an attack of appendicitis for which a female
patient had been treated in a provincial hosjiital, and dismissed when
the intiaraniatory sym])tonis had subsided. She was aged r>ii. The
growth was excised and an ileocolostomy performed, from which fireat
benefit wa.s obtained, the woman beinj; in good health when seen
several monlhs later. Here there was a large swelling left when she
had recovered from the acute illness, the importance of which wa.s not
recognised as there was no obstruction of the bowels. The giowth
probably obstructed the a|ii'ciidix.

Hyperplastic Tuberculosis of the caecum is a chronic disease,
and at lirst ])resents no evidence of swelling ; later this may bo
found in the iliac fossa, or even above the iliac crest, but as
time advances it surely becomes evident, whilst there are
increasing signs of tubercidosis in other parts, especially the
lungs. The tumour is more or less cylindrical, somewhat
nodular, and rather fixed : it may Ik- tender. It is of slow
development, and irregular aiidoniinal pains merge into the
symptcmis of obstruction. Excision is indicated if the general
state of the jiatieiit permits.

In Actinoinycosis a swelling forms and increases gradually
with a brawny infiltration of the tissues, followed by the
formation of sinuses, the ])urulent ili.scharge from which
contains granules of a yellow colour and hyjiha'. which show
clearly the nature of the di.sease. Some anu-lioration mav bo
obtained by rejieatcd incisiojis and the administration of
potassium iodide.

The vast majority of abscesses of the appendix diminish in

' ■■r:ir-:vM I>i;-t;;.-p.> of tiic .\j,{i. lidix. lU.,'' )■. 27o.

|( I

ill

LOCALISKI) .SUPPriiATION

l.-?.-.

size and bfconic nbM.ik'd or disappear by diM'liar^'<- into tiio
bowi'l, i)robably tlirougli tlic apju-ndix ; lliVrofori' it is unnrccs-
sary to intcifcn'. uiilos (1) tlu- abscess has become chronic;
(2) ni<rcaM-. in size ; (:{) gives rise to nuicli pain. Operation
isliould then be performed whetlier there is reason to think it
has become adherent to tlie parietal peritoneum or not. A
rapidly increasing abscess is a source of danger.

\Micii an abscos is jminting. having made its way through
the nmscular Avail of the abdomen, a simple incision "is all that
is rc(|uii'ed. with provision for drainacro

If the ])us is covered by peritoneum in tlu; iliac fossa, the
.^b•Hnrncy operation by >cparation of muscular fibres should
be done, the first inci>ion being made parallel with the fibres
of the external ol)li(nie. If the covering omentum or intestine
is adherent to the wall, all that is then nei ssary is to pass the
finger in between this coil of gut or omentum limiting it and
the parietal jjcritoncum downwards towards the appeiulix.
The i)us will then come away easily. If the abscess is not
adherent, a >trip of gauze should be passed around with the
end of a blunt-j)ointed pair of scissors and the abscess opened
in a similar way with the finger. Tn both a large tube should
be in.serted. In the latter the gauze plug may be removed
in thirtysi.K hours.

A ])elvic abscess may be opened after displacement of the
rectus muscle inwards and ligature of the deep epigastric
vessels, but it is usually ])est to open it through the rectum in
the male and young female, or through the vagina in the
married woman.

The patient liaving been placed in the lithotomy position,
and a duck-bill .speculum introduced into the Vectum. a
l()ngitudinal incision is made over the most prominent part,
dividing the mucous membrane ; the deeper parts are then
o])eiied up with a director, along which a closed pair of forceps
is j)assed. opened and withdrawn. This will sufliee to make an
opening large enough for the escape of pus and the necessary
drainage. After the evacuation of the pus and cleansing of
the parts as much as possible, a strip of antiseptic gauze is
introduced and left in the opening for forty-eight hours, when
It probably comes away during an action of the bowel.

^\ here the absccs.s is opened through the vagina, it is best to

f '

136

THE ACUTE ABDOMEN

shave the vulva and cbuche the vagina with stcnhsed saline
The cervix uteri .s .seized ^vith a vul.ellu.n. wlmj. is given t„ an

FlO. 19.— Si

.,19.— Sajrittal Section of a,fomale bo<lv uifl, .. ,.,,)) ^ i •

in the Vagina and throii^.TlT;, p ?' \.'' "^ ''''"''' ^''^^ m.orU;!

vaf.inal,lrainu,.e'^ tt ".Ch "f Moths', ^"""!y.*° '^^V'-'"" *''"

\?

'7m^^^'

J

LOCALISED SUPPURATION 137

assistant TJ.e parts are well retracted and an ineision made
bolund the eerv.x with th.- point of the knife directed up'^r
and towanls the posterior surfac.. .,f ,1„> uterus (Fi. ,.1/ Jt L

s the thuler. I he ,,us ,s th... ..vaeuate.l in a similar n.anner
the hnffer u.trodueed to n.ake the openin, iar^e enough fo a

tlH- M.lva ganz,- ,s ..arefuiiy pae)..! round th.- tube in the
yagn.a. and an ...xternal pa.l apph,.! M-ith a T l.an.lage T e
gauze ,s ehanged c-very day an.l the vagina .h.u..hed but t e
ube ,s uot d.sturbe.1 fo,- , ,,.,,„ „• ,„. whc, it n.av e
..■nov... ,f theeondition is satisfaetory. Heeoverv mav e
;l.'layed by son.e pelvie ..eliuhtis, i,. ^InH. ease there will be Z
irregular temperature for some tiuu'.

If the abseess ris,.s .lir.rtly fr.m. the p,.|vis and the MU.r,
J.ubK.pos,t,.nseho.enfor.b.ain.ge,the,^^^
must be def med. an.i op,.,,,tion only done Mhen that viseus
■s empty ,„,, „„, „f „,„ ^,^ ^,,,^^^.^^ . insertion V,f

and (annot fall mto pos.t.on when emptied ; it then lies well
above the pubes and would ).,■ in dan<rer

I tlnnk it is rarely p,.rmissibl.. to^.vtten,l,t to take awav

'-;■ Hpp,.n,hx wlu.n the abseess is opene.l. and that a mu h
better resutM, a large seric. of eases of varving seve t

e obtamed d ,t is ren.oved when the indannnatorv nd el^rf

ir:;!^:;'::^"'- ^-"-^~"if.ouwishtomak:

Sudden Diffusion of the P„, Jrrnn n„,„nr of an AL.ce.s
into the Pen'toneinn.
A most serious eonditi.m may arise through the bursting, of

-append-x abseess into tla> perit.meal eavdy. and f™^^
>M the experience of ,uost. this accident Mas a fatal om^ |„

ap,.n,hx suppuration there is an attempt made by n.L.e
Incahse the j.us : oe.as.onally for sonn- reason t ns is onlv
suecssul for a time, and tlu.re is a further extension of 1 e

zr:^j:w r ^^ ""^'' -^ *"^ ^•"^'^•*"-'"- ''''-^^-

P'ac. sIo«h and ,s not aecmipanied by the definite sLan

I < ,. ■ ■ 1 . ^ '

■Jmi\,X ^''--" ''■-^•'-s..I li„- .\|,|„,„i,, \,.rnul..|„ii- aiui tlui] ( um,,li,;,,i„,M-.-

138

THE ACUTE ABDOMEN

I ? ! :

wluol. wc; have, spoken of as <' poritonism." A very different

on .u>n ,. a large amount of pus has suddenly burst distri-
b" u.K ,ts sep,,.. contents throughout the ab.h.men.

L.xan.ples of this ..nnpheation whi.h were treated within
t.o^days an. n.struetive. and have been seleete.l as nu"

A ward maid at a fover lio^pital. agod 10 was ar1.niff«,i v

work on ,l.e foLvh^d^ and^ dTr ''7'"*^*' '" ''"'• '"'^ ^-""""^
until about tifto,. m. t ' ,. f ,^1 L "' "^"''' •^";""'' "''^ ^^•'" *- «>'" '•""••l

annepain .,u..k..d c I:^':;::^:^ ^^ 1 7;;^ ;:";;;:/ -r-

had been diaiihoa f..r two or tlnoe .lav. \r , '• '^"'''''

mind, and able to answer m.'.tlo,7s Tlu ? .^" . 'l'""- •'''"ar in her

ana ..allow, ihe lon.ne .f ;:;:ddn; ! :^:^'^z-:^::::;::^.

tlH.re wa. a markek re^Jl^: ^,:Z^ ^^^^^'^ I-'P'-vti'-
ally over the right iliac fos,a. where therr^ f d^/fj iTet ZT' "^T"
was ,aeat tenderne.. here; the abdomen wage^'XtSor O^

recovery, and later on the apprdL-la're/ntver""* ""'^ * ^""'^
Another case which presente<| similar syn.ptonis, and also
c-n. e, tn recovery was tJiat of a ntan age.i .3.3 years who as
sent to the hosp.tal by Mr. Haliam, and adndtte, th" Z-
foUownig the adtn.ssion of the patient whose ease- 1 have ju'l
recorded.^ J" '

cX'^ ^'''*"7." ''^.^^'''^'l.-''" •''♦^''^•l^ «f pain in the abdomen on October 31
ch efl, „,, „,e n,,ht „de, bn, did not «ive np his work, Durin/tle
n.gl.t ot November 3 an afta.-k of intense pain was experienced -^mll^
came to he hospital in the morning sixteen honrs later. Xn examined
he was found to be perspiring freely, his fa..o w.w pale and an^iZ
ookmg. respnalions were shallow and diaphragmati, \n attemTt to
breathe deeply eansod him „,uoh pain in the aCdomen. The p^Le^ll^
104. temperature I01.2^ The-e was no vomitmg, tl. "^et ,Z

Im^-^i'^'wsBiaMamijSL ^•m.'%

LOC -A LISED S V PPUR ATION

139

J

oonfmed. tl.o abdomon did ..ot ,„ove on r.^plraf io,.. .„.d w.-« very
onder on oxam.nat.on. cspwially i,. ,l,o ri«ht iliac ....M.m .,.71.. J
!«..... Tl,..ro was d,.l....,s. ,„ „..■ (lank. .,,,1 ,1,.. li^.p 1 L ^
obscured. The abd,„„iMal .m.s.lrs wc-,. ricid thi«, ri.M.l,,. '^

marked on ti.ori.i.t side In .i.c n.i.t iii J/;:r w^ ' , j ';;^,;;;;;:

swemng Atthcopc,.a,io..tw,. i.-cisions wero .nadc. ..;..:

noil.cus Oflons.vo. s,.„„.punile..t (luid wa« Ke.icrallv ditTused
tl o,.gl.out tI.o p,.r..on..„,n ; .ho intcs.!..,. looked very con.^^. ■ Und
.pdcn,a ou. ; .ho ab.ce.. had rupOnod .o iu ont.r 8ide. L^vl . wT h
salmo .l,..d of a to.nperat.uo of Ho „•,. thoroughly po.tn;.;! ,|
hepat... and splon.c re«io,..H h..;,.,, ,,,,vr„||y ini.a.cd: I.rai. n'^'' ,- .
emp loyod fro.,, both wo.n.ds. Thcso wno healed by Dece nb -r 17
and later on ll.«> api.e.idiv was r.'.i.oved. ''

In tl.is ,..,s,.. as i„ ,1,,. fon,..>,-, M.,,pu.-.ati„n l.u.l f„ll„^v,.,l
tK-rforati,m „f tl.o ap,...,„li.x bcy.„„l a sUkUuv. It ^vill 1„.
-^;;' tl.;.t i.. l.ntl, tl„.s,. <.a..s tl...n. was a clHi,.it.. fixll

Instcry ..f a n-vvui al.,l.,„unal pai„ ^vhi<.l, sul>si,|,.,| ,,, I,,,,...
vomilLr '" '' ""'''''" "'"^ "'"'"''"g rc'tu.1. „f pal,, and

OTJIER AHJXLMIXAL SIITLRATIUN.S.

Hkpatic Ah.S( ks.s.

It is ....t often that w mv the la.go al.s,...ss,.s of ti.e liver
wl.icl. us(-,l to com,, u.xlcr ohscrvation some vea.-s at;o Tl.ov
were frequently so vc.y larg,- that the patient was „ot o.ilv
mlueed to a skeleton by the aeeon.panying fc-ver. nigl^
«weat., and po.vs,|,|y diarrl.<ea, but J.e bad little el.anee of
siirviv.ng the sl.oek a.ul subsc.,,uent d.-ain Avbieh the release
of sueb a large a.nou.it of pus and elosij.g of >u,h a lar-^e
cav.ty en ta.lec on l.,.s resourec.s. 1 ],,,,. seen suc.h abs<.,.....s full
of thiek e hoeolate.,.oloured pus opened, and the .vsult has !„.(.„
a ha^morrbage into the c.avity in some or a high he,.tie fever
whieh proved fatnl m a short time in other^

TI... training of the jnemb.-rs of our ,.rofe>sio„, wlH.h.T eivil
or ni the Serv.ees. is .o much in.proved, and their ability as
operators so h.gb. that these eases no longer progress to ^leh
a dangerous extent. They are wisely treated in the ..olonies
and ,iot .se.it borne for treatment . wltb the possibility of >erious
complications during a voyage of unceilain duration.

R^«r

140

rilK ACUTK AIIDO.MKX

!

! i

1 I

Mi

tl

I i

Mr. ('jiii)lir h.is sii;.'ncs((d tliiil hi-p.itic ai»M-.>-.cs slimild lie
fmitcd l»y mciiiH of linear .iml <Miimila foll<.w<,| |,y siplmn
tlruiiiiiur : lie niv.-s r\<rll.ii( r.MM.ii, |',.r lli.' (.|..Ta(i(".ii uliidi
Ik- .•kIvoci),.-;, IhK I (In not kiKiw uf fiiiy >tati-tics wliich ciuil)],.
us lo.unipiuc liis riK'Hidil with (ho>r in ^.n.'ral iisc. It \v,„il<|
Ih' Wfll if lir coiiM jrivf his .-xact r.'siilts. The inajoril v of
siM-L't'-Mis, I take it, arc m..r.- cDiiifuital)!!" iis (o the roults of
o|).-ratioii for such al)sccs..-s if ih,y f.vl ihnt fhrrc is i.olhii.u
(o iiitcrf.MT with the frcccs.apr nf the pus through an opening
which llicy c(in>i(lcr more adccjualc.

'I'Ik' c, y evai'uation of these abscesses is to l)e rlesind. as
It is in t!ic ease of al>sccs>es in other parts of the hody. 'I'hr
majority an- situated in th.- upper an<l hack part of tin- right
l<'bt-of llie liver, hut there are no rea-ons « hy ^uppuration
should not .•onuuenee in any part. Those which lu'gin within
the liver, or which arc in tin- most common situation, may
po-sil.jy l,c pernntted to attain a si/.e large ••nough to enable
them to be searched for with a probability of success. 'I'hosi-
which develop on the anterior surface slionid be <i|)ened ipiite
early, and a long illness cut sIk.iI. We no longer liav<> that
fear of the- ju-riloncum. which fornu-rly acted as a deterrent to
operation befort- the wall of llu- al)sce.ss was adherent to the
parietal peritoneum. .\ plug of gauze can be placed to shut
otV the peritoneal cavity and the operation expeditiously con-
cluded at one sitting. It is not necessary to use sutures, '{"he
cavity does not r(-(|uire to Ik- scrii|)ed out neither docs it need
syringing ; botli may cause- ha-morrhagc.

»;. 11.. an ox soldier, ajrod ,'5.".. wiw admitfod -X- <iii .biiio (i. litn,-,.

He stated Iliaf on .May :iO. about !t a.iii.. he had a niiddeii attack of
vomitiuf:: he liadiio Iireakfast tliat moniiui;. On .tunc (lie l.si lie had a
dull aelunir pam in the iow.'ipart of I lie l.a.'k on t lie lijrhl sid.-. extending
in front to aliout 2 inehes l.elow the inarjiin ol the lilin and 1>J inch."
from the middle line, lie vomited several times dining .May :!(» and .•il
and .lime 1. He had I.een feveriHh.

'J'his patient liad I.een previously under tlu- .'are of Dr. Maek.'iizie in
l!M»4. from November S to Deeemlter :il. and on Ndvenilier 11 an
abscess of the liver which had been cjiusiii;: syniploms for ten days was
opened and drained. Ihe abscess was a small on.' conlainintr fireeiiish
pus. which was sterile on examiuiUion in the .linicjil hibor.itorv.

The surface of the liver was dark-red in colour, and the absccs.s
was not bnlsrinir. nor the liver adherent, but the area underneath
which the pus had .'ollected was softened. I'lie point of a pair of

-.V^

Jl

OTHKIt ABDOMINAL Sl'IMTHATION.S

111

.iilci-v loic..|(s WHS |)iiHh<'(l into i!, I III' li.ii|.|w i.pciK.d, witlidniwii.
unil li'|il;kri'il liv li iillilii'i liiliit.

'I'lic iiiiiii liail lii'i'ii III lii.lia. Mall.i :iih1 >iiiif h AIii.h. ami liitil .^iillfii'd
In. Ill <l>-,riil.'i V III IsHT, iiiid on iihik- limn om. oiiii-iun Hinr«. Il« liad
iiUo liiid ciiltiir In Soiilli Aliica.

• In lii^ s.rniid ;i,|nii,s|,Mi ihit mall li.ok.d ill mid Iiih Iim-hiIiiiii,' wom
liim icd. I •.•<•]( iii^jMi jil ion cnusfd shiii |i |iiiin. 'Hi..i„ win I lio s.ai of l lir

pi.'Vimis o|M.|i»lioii III tint iiy;l,t, li\p<Hlioiidiiiim. Tho liv,.| .dt;.' Id

not lio ti'lt lpf.iiils«- of I lie ('xlMiiif KHisi.iiir.r ol I Ik- iii;lil ivilii-i, miii-li
leiidcriKMM WHS <om|)liiiiird ol. on cviii IikIh pi,s>iii.', ovfi I Ins aicji.
'I'llfl.. WJH no liji'lion lo I.C h.aid. A dia^xyili;; (laili wns raiix^l wli.ii
III' tiirmd on lli.^ |..|| miIc, and li.' w.im iisiiall\ loiind l\iii;,'oii I In- liylil.
'Hid livci (liilii.'>s.'\l.iid.d v.iii.all.v dounwaidrt lo 1 iiicli l.clow llio iil.
niainin. Iioin llio lllili ijli. 1'uImi, KM; n-piiatioii. -t 4 ; i»;miM'iaUii«),
KMi-i' . 'I'licio was nolliint; iil'iioiiniil found in ollici pails.

II IS Hyiiiploiiis did not iniinovo. oi, .liino lo li.; was iiiial>l<< to ^l.'.-p
LecauKo ol pain. On tlio llili an im-ision was niaiio iliroii«li ilir ii;;lit
rtjrtus ; on pasNiiiK the (in^'.r alon;; llir aiiliiior siiilaco ol lli.' liv.T.'an
ait-a ol l'iil;,'inK was louiid lowaids I ho Mimmii, tlio ii])p<i pail of wliicli
was soli, wliilsl 111.) pail at iIk' l.aM' ol ilic projcci ion was nmliily
ifsiKlaiii. 'Ihis una was i^ilalcd with Kanzo j.ai'kini;. a liodiar jnil
inio III.' >wt'lliiit;. alon;; which a pair of lorccjis was jiasscd and <'\il
Kivcn lo ahoiil ;i oz. of yellow jms. A diaina;;o liilio was piai-cd in I his
and Ihc area slinf oil' from il„, ;r,'ii,.,al iHiiioncal ravily Willi a si up of
jiauzc. 'I'lio tcmpi'ialiiK! In'caim' iioinial al omr ; in ihico da.Vn' linio
Ihcio was hardly any disihaiK''. ami Ihc wound had lic.ilcd icii days
after I lie ojicial ion.

This alisccss was nearer the middle lino and less accesf>il)le than the
former one.

I'ki{I(;astj<ic .a.nd Sihdiai-ii... • \nsr;F.s.s.

l\li(J(t-<ltic A lisrrss

la casi's of lociilisi'd supimratioii ^wu\ 'liiry to ju'iforation of
a gastric ulcer, tlic o|)ciiiiig i.s usually a small one and tlic
abscess forms oradually. There is a h'>tory of gastric ulcer,
with an increase of any j)re-existing e[)igastric tenderness and
pain ; swelling in the stomach region, which increases from
day to day, and a feverish attack. Although we do not find
any of the food contents of the stomach in these abscesses,
the .smell of the evacuated fluid is >o characteristic that no
one can have any doubt of its origin when the {)us is released.
It is often impossible to find the perforation. There is some-
tinie.s bulging, fluctuation, and the presence of free gas in
the.se absee.s.ses. The snuvller ab.sces.se.s are rarely diagnosed
and have not infiet^uently pro\i'd fatal front secondary rupture.

'^^\'':.

:li

\i2

'IIIK \cni-: AHDnMKN

»

m

whilst ll,,. I,llprr..||,.,ll,„l> ,uv hk.ly to ,.,ll,..- .Iriilh finni
«xliaii,ii..i,. (ill.MK a> III. V nmy .lu ||„. „,,,„., ul.,luin.„. \VI,. i.
(li.M. ;U..r,ss,.s .spniul .ln«„„ar.|s i|„.v „„„•• pnrnilly run
alnnn tin- Irit H.lr ,,f tlir s|.li,.., „,,m| alM,,^- ,|„. „.!.■ of 1 1...
th'M-.'IKlm^; rololl. Iliail brllinil III,' |M'||tolir

'" '; •^"- "-■'H«''l "1.1, 1... S \\..,l ;H 11... l;.nal !•,...< II.MIM.^I that

«as ih,. ...M„s.. h.k.u. an.l .1... al.s.rss ha.l H.lai.HMl ;i h„K.. «,/.., at 1 1...

'""" " «"•" "1 'l '" '•"" '<'•' 'Iwi sa. !|„. ,,a .1.;, wnma.i

n'f(>\('ii'(|.

Tlic |.o>Ml.ility of a Mr.d fur , (mihI.i o|.,.nii,^s ,imi>| Im-
.•..nM.>..|v,l aii.l a, .anlul ual. I. k,.|.| loi >,;;„s of .nvolvini.,,!.
nl (lie plcina.

All al.stiaci of a imho .Icscii:,,',! m a , nini.alioii to th,'

Nt. 'riiomas'.s Hospital Hcpoils is of int.nKl' :

A iiianira woman <.l I'ti, ailimiicl -X- n,i„|„.r j;t. umil' sin Ind

Ixvii ...nliii.'.l ..II AiiKtiHl (1. an. I a il m.v.iiI i .la\s Jal.T l...nan '(„

'■""'I''-"" "' !'•»'" "> I"»v.'i .'h.'si. wIm..1, ,.m,.,„|...I .'l„wn to ili.< ir.Mii

pari ..I ll,.. al..l.„n..n. Iln.s was v.mv k..v..„.. «..|„.,allv .•;lnl,^ ..i, alh-r

liikmc I.>.„1. an, I I,,..,,, \y .aus,.,! v..imi,ii^r. wlil.'l, ^mv,» n„.nt i,.|i,.f

Cii a.lmi«,ioii ll,..,.- «as a kw.'IIiiik' m iho uinl.ili,.al i,.j:ioii wlii.'li was
mniul.Ml aiul «ii.o.,i|,. AIm.vo il was a vor.v l.anl n.Hliilar mans tlu- m/o
of an ..rail-,', wlii.'h apiM-ai.^.l lix,.,! an.l ,li,l n.>i m.,v.. w-ll wiili r.w.Mia-

tion. toniniiious will. tins. Imi ,1..,.|„.| in ih,. alMl.,ni..n. wiw as ||,

rotnuW niiiss. wlii,'l, ..M.'n.l.'.l l\ nnlu's l...|ow i h,. ,im;,i|i,.|,s i,.,,,, ,|,„
nii.i,ll.« In,., to III.. I,n.. ot il,.. n^lu ,„,,j,|„. yIiis als., api...ar..,i tlx..,|
1.,^ nnm.loa i.i„n„n,n.v ,i, ih.. ..pivMsi,,.. ,,.«io„ wa ..,.oKnis.Ml as a
.lilal.'.lsiomafh, ili.> f;r,.al,.r .•iinalniv ol wliu'li i,.a,.|i, >, iiu-h.-M l.,.|„w
tho uinl.iluMis. and to ll,.> l..ti n.-aHv i,. il„. im.l.H, ,,; ■|.|„. |,,^^,,,.

.•nrvalui,. wiis jn,>t l.flow lli,< nu.st pion.iiu.nl p; . oj H,,, ,„,„

I'.Tistalsis wa.s poorly -naik.'d. Tlui swllni;; wjvs ..vti-.-tiH-lv painlnl
on inv^siii... ami slio foinplain.Ml of a moio or l,>ss ..oni iiiuoiis acliini: at
all tiiiK's. ^

t)n Nov,.nil„.v :. tli,- ,.pij;a,M ri,' sw.'lliin; h.ul iii..r,.:.M.d in siz,^ hut tin.

t.n,p.Talm,' was normal. On il„. sil, il„. p.un had h, ,„,. n.-.n,-. and

Wiis noi r..Ii.-v..d hy v.)niil iiij;. Th.. i..inp,M a! ui,> w;w ajjain .'l.^vai.'d. ( In
N<.v..mh,r 1 1. L'» ,./. of nils w.r,. ..va.Mia .,1 ihn.iij;!, a in,.,li.in ,.pi.Mslri,.
nu'NM.n. Th,. Iliiul wa.. liisl ..| a .v..|l..wish wal.Tv app..aran.... ami

ihon iMi> hko inall.r ,>s..ap,.,l. a war.ls hloo,l-,siaii„-,l lliij,!. -I'll,.

• avily «a l,i;,l,..l in troni ..I ih.' .>l,.ma.-h ,iii,l..r llu- liv..,, h..iii!; shut
"tl I'v adh .ons of i|„. .,m..imiin to ili,. ah.lo, filial wall. .V ,lraina".<
IuIh' Wii-s ins,.,|,.d. l',,,. ;i |,,„. days pi„i;,,.ss was -.uhI. hiif ilu-ro w*s
asaiu .■..mplaini of al.donimal pani. ami on ili,. iHih anotlior tliu'tuatin^'
swillnij; wa.s found exlouding down towaiiU th," loU ilia,' fossa. An

1

'^^'l-hroinc IVif..i:,ti,,n ^.f a (iaslno ricor," by \V:Iliai„ 1|. Haul,. (^Vol. XXXI.,

HTIIKK \I5|)t»MIN.\l. SII'I'I i;\T|(».\s

ll:i

m.M,,,,, wa,,n4.I.MilM.,,.L'< ,n.l„..;^|..,vo, I,., I.r. ;,„..,..„.,.,., »„„,..

"'"'" '^"^'W'"" "I..n...l .it.-r..„„,„.,„..l . „ „n,„.,|«..v..,..l ouM.-.M

K .rl„.,l ,„KHlM., a.Ml H a.a.nuK !"• |m.. „.. Al .1... ,;„'.,. ,„ ,„

..n...,..v,. wlnl.„l. «|..„«|,. ,...s..,nl.|„„- hIomuIm.,1 ..„...,„,.,.., wa, ...K.,. .....

-.1 rl... I..K .... .„..,.,..,.. T... ,Uy, I, .., ,|..„i,|, ,„ „„.,|.„ ..|,;i„,.-..., w,^.

iHUov..,! I.,,,.. tl„. I..U.., „,..,H , ,.v..l..n.lv .l.-..v.a In,.,, .|„. .•,.||„|..,

.pH...-. \l.o,.. I.. ...,., „1„., , .,.., |,..,,„. „. ,,,,, ..h.v .■..l..„r...l ., n„.l

tl... .I.«.l,»,>;„ f„.„, II,., |„w.., «,„„..| ,|..„„..l ,|„. ,|„.,„„j,, ^,„,,,„ .„,.,

.v.'ll..w ; .1 .•.,.,l„.„...| I.., ,, |,.,v .lav,. a„.l ll..„ .-...k...,! |;....,,,| i,„.,

n,« .on,,....,......! iill. , II,.. I ,,, ,„,., ,,„„„„„„, ,,„. ,..„ ,, ''

.nt .1,.. was ,...,m,n..l i.. i^l,.. -„ |,„.| ,,,|,„..,„ i., ,|„. „..,„;„'

K«|.|(v.',y Wtts |.oiii|)|..|...

M WiiH „„li,.,.,i ,|„u ,1... ,.iH,..,„ |,...| ,„, „„„M.al a„.,„...( .,1 l.„.l..,„,.„,

' •"■ """ ••!"«^'-'-'.- MV..II,,,. wl,..„ Kl,., „;^ a.|,.„l,...|, |„.| „,„,, ,,,.'

"'•'••"..■...•.. ..I ll,.>s l,a,|. ,...,uk ..I ,....„. .... \.,v..,„|,..,. s ,1,,,,^ ,,,^ „,.,,„,
v.-,y „„t,k..,l |„ „„i,....i,„ a .■.,„:i,l,. ;j,,„„ „| ,|,„ ,,„„, ^^1,,,,,, .,,„„..,|

In M.i.i,. ,.,.i.,., ,M.riK;.s|,i,. j,!..,...., ,. f.,,-,,,.,! .....r.. r;,,,j,||v
I" n.yly iill ,M.i,.|, illi,,... „.,v |„. „.,,,,, ,,,. ,.^^,.,^. ,,,,.,^^^;^;
Mm.uI.I fl,,. p„H iiiukc i(. way I,, l.,n.l ll„. ,i.,n,;„.|, ,,, ),,,,.
on«,„at.-<l in an ul...r ,.l., ,.1 „„ i,. ,.,.,, ,.,„„• u.ll, , -,...,.,,,11^
If tin- |,..rton.l.,.,i i, la.-.., .1,,. |,n„.,.,. „, Mipi-iuatioM m,.\ \u-
v.-rv (,.,lMM,s an.l ..v.n lalal. |'i„-|h.,i,| ,M.,f,„atHm." an-
rcN|M,i,Nil,l- lor a lar;;.. i.,im|„.,. „f ,|„..,. aJ,-,.,...,.,. (v,,,. 1,.^,
«.. b.. (alui. wh.n (l„. |„.nt..iM.„i., i, ,.,„.m,.,| j,.,, ,|„. ,,,„„,„'.|,
wall (if It IS a<ll,..|. lit ) |„. ii,i>tak<.i, f,,r ll.c wall of an a!,. ,■,•.«

SiilnliojthiV'jmnfir . | l,.sri .v.v.
A I....ali>(.<l ..„||,.,.|i,.n „f ,,„, „.|.i.l, is in ,.„nta..t u,i|, ,|,..

..n.UTsurtar,.„f)|„-.lia|.l.n,uM,. \VI,..n ,„.,f,.rali..n .,rM.|.|.ura
turn ......urs in .■onn...-ti„i, with ,|„. ,.,..n,a..|,, .l.„„|..nun. liv.r

luid bile passa«,.s. pan.ivas an.i .pi,..,,. f|„. p„, ,vil, pn,},,),!,.
hav.' s,„m- relationship ,„ t|„. „,„|,., ,„,f.„.,. ,,, ,,,„ ,y ^ ^

Suppuration may also ..xt.i,,] from tl.c lo^i' part of th.^
>^Mouwn. The laf Mr, I'.ainar.l analvs.-.l tl„. ,.;.„s..s in
-<. conMrutivc ca^.s Ml.i,.|, o,.,.„rr,.,l at tl... I.o,,,!,,,, ||„sp„;,| •
L'l vore duo to ])(Tf oration of yastrio nicer, li' to .•,i.i.,-n.li.iti>
Lf.tJ., who colkctfl 212 ca.s.-s. says that 74 w.-r.. ,|,„. ,., .a^tri.'.
ulcei and 20 to appendicitis. The proportion ^ivei, bv th.-
former is probably the more .orn-et. To the affectio'ns of
I he organs mentioned are included, in Mr. Jianiards list
parturition, p^a.mia, spk-nie infarct, extension of thoracic

144

THK ACtlTK ABDtiMKN

■ I

I ^

I i

I [

I >

a I >

' i-

I

(.li>«'rt"it', r M' ptri<>-«titi> ot triiii-\ti-r prmr-.- ot liiinliar
viTt«'l>ra,' ■ •« till <>|H'nitt(iiH. tyjihoid pyu -iil|iiiix. iiipliinil
mit lOiimMJt.i 1 \>tic kiiliU'V. aiitl injury.

'riuTc will i II illy he ii history of sninc 'ivu^i »ii<li ii> ii.i-liii'
iilcrr for t iitiuii of an al)Mt's> ui I lie tipprr ahdoiiiiii —

pain. li' I vomiting aii<l incica-itl Ity takinj^ fnotl ;

hu'inat I • . attack <it (ly^tnlcry typhoid malaria, 'i'lu'

oHM't n. \ I !■ -II 'dell or ipiitf in-iidioin and pain is tlif lir>t
!-yinpton, V • iny i- vj'ry •onnnon. rsptcially ni ca^o

Fig. 20. — l)iuj:iiim nf tin

Almtolllitill licliltinll> lit ;i

Ilif.'lit-Mnl('il Siiliiiiiipliiii;.'-
iiiatic AliMc-- (Inmi " Siii^'i-
t'lil l)i-('ii>es lit the .\|ni<ii(iix,

<'t(,'.,"2ll(llMl.).

•Jl. 1 >iiiu'i:iin lit till'. \n;ito-
iiiiial Ui'liitiuiis lit' ii 1,( ft-
>iil I'll Siil>iliH]ilir;i>.'iimtiL'
Ali^ci'^^ (t'niiii " Sur;.'iriil

l>i-l'ilM'> lit' tilt! Al)IH.'lllll.\,

ctr.," 'Jliil I'd.).

where perforation lias occurred. Aiiiiiiii,'st the general .-symp-
toms i.-> pyrexia, which varies much in severity, is frequently
accompanied by -weating at niizht, and gastro-intcstinal
disturhaiice. Uigors are of bad progno.-is. JA'ucocytosis
was found in all the case- in Barnard's series which were
examined for ii.

As regards the abdominal signs atid symptoms. In most
there is an abdominal sweUing caused by the purulent collec-
tion, or the bulged liver ,-ubstance over a tropical abscess. It
does not move on inspiration, and varies according to the
particular anatomical variety present. There may be bulging

' Sec ako V.ajoT .Maddock. Britith Medical Journal, Vol. I., 1914, p. 862.

■jm^M .:^imi^K:' J

-^fML^-U!^^

OTHKH ABDOMINAL Sl|-|.r|{.\ IFOXS , ,.-,

'.•-.■» f.m-ar.1. .1... al.-ln,,,..,, will b. ,L\.r an.l ,| n

l'<'''><>iwal rub Iwi, b.-,u Im,u-.1 '^

Wh.n the ,M.s is b..,w..,.H „u- lu..r ,,,..1 .l,a,.l„„.,. ,1...

-. bnn. adlHT..,,. a, .1,- .narpn ,.f ,|,.. .l.-../- .L _ ,

UcM-fiid Oil iii-|Hratiuii. '

ChuM;:cw at tlH- bax-s uf ,|„. I.H.^., M.av in.li.n,, . K„,„i..„ nf

mtlamniatiMi, ,|,r„„i;l, tin- dia- \i< n i..iin|

t)lirajr|„. „r a .oinprv-,!,,!! ,,f tli.-

liiMii. liarnanl r.'c.r.l- the prc-s,.,,,-,.

of ba>al >im,, .ai ||,r u|,p,,M,,. si,|,.

Ill two ci^cs ,,( p,.rii:a.,tric ab>cf>s.

The mcaMin-m. lit of the air.-ct.--l

sill.- is of(,.„ in, ■r.-.is.-.l. whilst biilL:

ill),' may be .-asily >,-<-ii. or (Ik- int. r-

••"-lals arc- pri-ssc.l outwar.ls and

tli<- tissues f,.,,i ,i.d,.n,at.)Us ..v.-p

tii.-sc nmscl»-s.

.^'ubplin-iii.- absf.oss.-s shoul.l be
tr.-atrd as sui-b .-olL-.tioiis are
tn-at(-d ill otJuT parts of tli.-
■■'l"l<'tiu-n ; if thoyarek-fttobecoino
very large the cbaiu-rs of rocovt-ry
are imi.-h diminished ; still it is sur-
prising; b.tw rapidly a young patient
may improve even after months of
<I«-I.iy, when the abscess has be.-n

<'mptied and drained. In 23 out of - -

liarnanrs 7(! eases the abscess ruptured— uito a bn
right pleura. 2; left pleura, .-{ ; peritoneum. 1; .,o„.
'nt.-stin,., 2; colon. 1 ; through the skin, 2.

In the ,liagn..sis of these abscesses X-rays arc useful if tl,.-
tate of the patient makes it possible to appiv them an,! tVere
>s any obscurity in the case. The use of an' .-xplorin. , . i :
s not a. vocatod ; it may be a very clang.-n.n.: weap. n
ery mts eachng : there is more than one case on record •]" ■«
1.0 needle faded to find the pus, and others where it ca,, - a
latal r.-sult. <oislo a

A. A.

I.

iiciMoi, i..r.A|,l,,ri„j,ti,,,
avrht S,.iK,.,i,,hn,j,,„;,,i,.

H.'jjion (i'riiih

I»is(':is(is of fii.
"tf.," L'ikI

' N!ir-i<-iil

'';'li*''i'lix.

'IMS, 4 ;

.i<h. S :

' '

:nv

III

!!

lii

!?
u

M

I

I4G

THK AIL'TK ABDU.MKX

The sul)|)lirciiir ah cess iiiiiy Ix- salisfactoiily troatod by one
of two inctliods -

(1) Kxposiirt' and dtaiiiajic from the fi'oiit wlicn tlif abscess
tends to ])ass in that direction. Ii the al)scess has not reached
the niarj;in of the ril)s. but is situated between the upper and
anterior jjart of tlie liver and the dia.piua<,Mn but is not under
the liiu- of incision, tlie peritoneum i- packed olT. a (injicr j)assed
ujjwards into the abscess and rephiced by a large rubber
tube. Tile abscess is waslied out gently with sahnt solution,
and a layer of fresh gau/.e placed to prevent escajie of any
pus into the general peritoneum. This can be remo\cd in
thirty-six hours.

(2) Jf the abscess is behind and al)ove the liver or above
tlie s|»leen. a section of a rib (the ninth is probabl\ tlie most
t'oinnionly selected) should l)e made and the pleura opened.
If the (Uaphragm. which is often (edematous, is adherent to the
pleura, an incision of 1 ^ to 2 inches should be made in t he middle
line of the wound, and the upper margin of this sutured to the
pleura, if the pleura is not adherent, a line of sutures should
be passed all round, sliutting otf the pleural cavity. Whilst
these sutures, which may lie continuous, are pas>ed it is well
to have the dia|)liragm which is exjiosed held up with forceps.
The incision is carried through to the surface of th«» liver; if
the ])eritoneuni is not adherent, then a plug should )»e passed
and packed into the lower jiart of this >pace before further
exploration is carried out. The foretinger is then passed along
the surface of the liver in the direction in which the abscess
is supposed to lie. a bullet probe being substituted if nothing
is found. Where tiiere is a j)robability tliat the sui)piu-ation
is in the liver, whether tropical abscess or suppurating hydatid,
a trocliar and eanula is passed into it. the opening (^darged.
and a drainage tube inserted. In any operation of this kind
it is well to make certain that the peritoneum is ipiite shut off
before the incision is closed.

Drainage will be rerpiired for some time, and the surgeon must
not be hurried into shortening the tube or diminishing its
size.

Suppuration in tin; splenic region is usually secondary to an
attack of appendicitis with spreading inflammation of the
peritoneum some time after an o))eration has l)een satisfactorily

<>TIfKH AHDOAHXAL SVvniiATlny;s

|U'i'f(iniic(l for fi,,. ..,.,.,, , f ,1

■<■■' aill:.n;: ::;,:;,::;-•■'';:■'-",'-■ "■•'"■I.-,.

I \l V I , filed. ( ;|l,(.|,,, I.' 1. ,...,

"■■■"« '.-!-.« ;',;;:,■:'::':''',;;: '■'■"''■':™ '

"liK-ll !..• ..|...,|,.,1 M.cl. -,1,.,,. . ' ,, - ^'^ ""■'■"' "'>l.nir,.> ,„

• "if points (,a whi.li I ,,.|vi,, „,.,i ,„, ,

(-•) l-M-al ..vul..,,,,., ,„ .„„.,,„„„ ,/;;";'",""" "'■■ l--'l'lMT,d l.|.,.„i .,
''<■ "•"•"'MS ... an.as ,„ I. v,...,,,,.,,! ,,"'""'>■ '"•'"■■^ "' ""• >pl....,i is

'"•■;i.l, iMslaiir,..- ' •'"""""" ""•"'t'''tiiijr„r.a.,iHiii

1 nifc»,,r R;,,i>(.lin(l- I,;,. ,,,,1.11 1 I .

"I lll(> .sii;i!i

"■■'liiui-,. and .■...•„v..,v 111 iln,'..'u"V""'V"'"''""''"'^»"l'

a^vd !. nion.lis, ,1...,,. ,,,, ,„ ahs.' ■ , / '■"'^" . '" - -■"-'<l Hiild.

I'Hd b.-..u snilniu^, fn.n. ..n,..,„.,.„li,i: , , ""^"•-'f""""!- ''''is ..lul.l

w..h o..,.as,onal passa,.. of |,,.„.,, a , ,."";";"" ''^- ''•^•■■■- <l'-'l-a

Tl, " •" '<'''itl tcii.siriiis

<"oN(ioAi,i.:i) Ans.KssKs

tlol 1 l.,r fl.,., . :.. . . '' " '" IlK' .■Ill(l(.ll|,.,| . tl,....,. ;.,

■'<•'■'. \'.i\:

p. I:m:

h2

"i

f

1 IS

THK .\( ITK AliDO.MKA'

W 1

iiuMit ^lioulil be ciiri'icd out as indiciitcd in whai lias bi'cii said
altdiit otliiT alisccsscs. 'I'liosc in llic kiiliicy rcj^ion ma.y Iti'
mistiikcii fdi' sii|i|)iiiiitinii (iiic to appendix disease, hut this
will he ascertained at the uperatioii. for the odour of the |>us
is eharaeterislie.

At the Children's llo>|>ital. Shadv. ell. it was not iniusual to
see eases in whieli ah>ees>es were pointing;, or already diseharj^-
int;. at the innhilieus ; these weic usually reszarded as pi'ohahly
luhereulous in oiiijin : there is nodoulit that in many insliinees
t hey are caused l>y the pncuniococcus. aiul in such t lie proj.;nosis
is flood.

There ai'c. liowe\er. nian\ instances of concealed ahsccss
met with in practice, the |)osition of which is not easily ascer-
tained, nor t he cansediscovei'cd. when they have heen found and
s\jccessfully treated. Some of these are i'esi<lual ihseesses
following on suppin'ativc ap|)cndieitis ; some are of tui)erculous
origin ; others originate in the |)elvis the result of tubal
disease ; whilst othe?s ha\-e their origin in the liver, or possibly
in comieetion with a malignant growth which is of itself too
small to .gi\i' localising sym|)toms. I'ain is not a. characteristi<'
symptom, but the patient becomes feverish, listless, loses
weight an<l sti'cngth ; his complexion is pale and muddy.
The tongue is furred, the boAvels constipated ; he has no
apjtetite. and sleejts badly ; whilst in the morning his <'lotbing
is wet with perspiration. Tiie ptdse is increased in frecpieney.
but there is nothing ahnoi'mal found on t'xamination of lungs
or abdomen. Ivxamination of the |)elvis in women may show
evidence of suppuration about the litems, but there may be
nothing ahnoi'mal discovered. T\ phoid fever is suspected,
but the tests for tlnit and tul)crcle are negative. The blood
is examined and leucocytosis is found. incUcating the presence
of supj)uration somewhere ; tlu" ditticulty is to locate the
abscess, 'i'he sui'gcon nuiy suspect that it is in the sub|)hrenic
region by exclusion of other places as a result of examination
and the history of the j)articular ease, but it may still bo
impossible to point to any one localising sign. Here the
X-rays may be of use. and comj)ari.son of the mea.surements on
the two sides of the chest should be made.

The folloAving cases will illustrate this part of our subject.
In tlie first, under tl'.e care of I)r Bn\-. it w.as thought that the

OTirKK AHDOMINM, Nl'|-|'n;,\T|o.\.s

I li»

pHliVnl inif,'li( |i;iv<> had

"'""«'' tl'is was i,n( |,rov,.,|.
'Ill

""'"l'l"''"'i'"i-.i^^. .■,i„M.f„r(|..-,lK,.,i.,

w;;j;:;;7;-i;n:''V:!^r:r,;r^ i-...,,,,,. „ .,,.,

Auunsi 1 and .•o,„,.luin,.,I.M ,.■.;., ■'■ ",''•"" '" ""■ ■''"'"'"..■n on

•'••"• <'|.i-*«axiH on and T , -^ ''"" '"".' '"'" "'"" ''''' '""'- "'-'

<»n ii.lnn.sj„n l„. had a hinnrral ,.,.■ .,1 Mi-' i , i
"' any><..„.n o( ,|,.. l.o.U T , V "^^ "'"''""" <" "- aLlon.-.M. no,

;-;■>■■-'■■ i' •nn'./;:;:;:'::;:; ':;;\r;;''rr ^'"."'^'

t.V|.iioid. nilHTrl... and svniiil, „ '" "" '" "'^ '"' l'a>.U y|.hoid,

a''.l..n...ndisa, a -..d . •, ' ,, " '' """'"""'■ ■''"• ''^"- '" "-

tliiipliiajrni moves Ics-i (|,a,i |,.|i
screen cxarninafion." 'Ilien

•n Se,,|e,Ml,e, --1. ■ |.,.|,, „„.
X'nie o|,a.r(y ol ,,.1,, |,..i„. ^,.,.„

("■•■■-^niv over. lie lower.il. V,„ Tl '"' ;'"''',"' '''li'n'.. lenderne.s ..„

1':-- pi-,,;,;:.; ■;:;:■;,;.:-;.:: ;,'■;:' '• '' "^'>^'--

Dnrins: II '

ol

IIJ

on

I'l a M-..m,l .MS,. iluTf ,.„ul,| h.. „., ,|.,ul,t fl,.„ ,1,

w^i:"i=;;r^,S^.ri;:;L;;;,:-:i';^,;;,:«-|;-: ->....

«».' it. ™«. mt :t ' nr';;t,;'ir ; ,-" ,"

tinned sine,, wirl.ont anv lon.r i,,,er,„i ■ , " , " ■".'acKs have ..on-
•rouble have been sU^h./ei J,,'' r^; ;':;„';:!; ^"^ " ""^' '""'*'
sharp ,I,ara...er. whieh in one in.Va e " l" ',>'""" "' '^""'••

short (Inritio- 'I'l .■ r '"'^'■"'•' ^•'-■* I'-llowed l,v a'lndice of

•'" "• ^^^i'^t'"^t i'ad been under observation ;.,..„:.;...:/

'Mji

ivation and treat nienl

iBi^i -jnnTrTt ' '^ . ;.;j»v,:ai2r^K«

>«iXBir.7iija f^.^n^"<r^i.:=iji MsanaK

.".(»

TFIK MVTK A]J])()MKX

Miicc April. ;ti„l ||„. inniHiatinr ha.l ^|,„wn a wry ina.k.-.l rail".'

Irom I(..-i at i.i;;l its an.l vwu !•: i,i ||„. nionn,,:;. It k.].! Mrirtly

i«> Jiis bfd. Ilic t..in|«ialiii.. u.Mil.l I.,.,..,!,,.- normal. ..iilv lo irsinnf tli.-

I-iVMous .oiii.s,. on his ntiiin 1.. u ,„ a<Iiv<. lilr. On .Inly -4 llic

«all-l.la.l.l.i an.l .Incts ^u■i,^ vk],U,u;[ I,v a Miin,.„,i \\U„ iia.l Mi".r,.si,Ml
the jMWMl.iliIy <>l a -all-slnn.' iniparlic.n in ih,. rvslic .Inn. \„lliin.r
alnionnal ha.l Immm, lonn.l. howv..,. an.l 111,, pn.^.v.. „l tl,.- .as,, lia.l
l»-..n Iml U.nipcdarily nil,.irnpt,..l.

nil Anj,'iisl .-! a l....alis,.,l ,luln,.,- ha.l >h,.wn iis..|l al lh<. ii"lit has,,
.iml oil 111,. ins,.|li..n .,) a Innhai an.l .annla. ..I.'ai- llni.l ha.l .■..n... awav."
J his (lull aivu wa> i,...ni an.l n.,l ,.l laijr.. ,..M,.nl. Tii..|,. had h,..'!! s,.in,-
t,.|i.l.iii,.ss al.ni- Ih.. nnilii ini,.is](ai.L. sin..,, ih,. Ia|.pinj;.

Th.. ])ali,iil was a lail man. nin.h ,.nia..iat,.il. II,. hTul a lapi.l j.nl.s,>
tli,( tnii,, (.1 whi.h was n.>l !;,„„[, |, ^vas .•xplain...l I., him th.-it thciv
was an ahs..,.ss ..I ih,. liv..|. h,.Uv'...u tin' iM)sl..ii„r asp..,i „t ,i,at ,.ij;aii

ami Ih,. ,liai.lna,-m. and Dial il was n,.,.,.s>arv l ...n il ihn.n.d. Ih,-

cli,.si wall.

Part ot Ih,. i....-h lil, „n ih,. li-lil si.h. wa. ..\,.i>...l. th,. pl.-nra snini...l
t»th<.diaphia;rni,an.llh.. in.isi.,ucaiTi...llhion-hthat mns..N.. .^.v.ial
la.i.',. v,.nis w.'iv visil.l,. in it. ami it was sonnwhat ..-.h.inaUjns an.l
a,lh,.|,.nt I,. Ih,. hv.T. A li...haiwas pass.-d ml,, th,. iiv.-i. npwanls and
mwai.ls and pns l.,nn.l. Th.. .iiMnin- inio Ih,. ahs,-,.ss was ,.nlar.'..d
ami ah.Mil l.", .,z. ..I y..||,,w pns ,.va<.nal,.,l. Tw,. ,liaiiuiK,j tul>,.s woi,.
nis,.ii,.d. 'Ih.. a,ld,..l .Irain In.m tli,^ al.s,.,.ss was i„„ mu<.li l,.r the
Iiationt. wh,) dicl ,.\lKinsl,.d a few ilays all, 'i wards.

Jn till' ,.a>(. of a _\oiiii<r la,|y ,,f Ki. who liad l)t.,.ii uml(.r
ticatiiifiit for >om,. weeks for t,v|)lioi(l ft.vcr. tlic cauM. of tin-
syiiij)1oiiis was a lulx.rculous |)y.).sal|»iii.\-.

1 was ask,.,l t,) ,ip. lal,. l.y Dr. .Mackenzie, wlio Jia,l si.,.n ilie patient
in,-,.nsnltaii,.n. '1 he ,lis;,nil,.,l inl),.e.\1eiid,.duiiwai,ls int,. ihe imsterior
part ,.l Ih,. I,.tl iliae lossa and tlmtnated. f^hv had L.v.r and was niiicli
,.niaeial<.d. Oiierati.m (.,.n/irnied his diainiosis ; th,. .sw,.|liii^' was very
adherent and dillienlt to si.i.aral... heinj: very eli,s,.ly atla,h,.d to the

til>l.,.r part of the r,.,-luin. and allhonjrli i p,.niii;: ninld he lonnd al

the tim.. (d ,.ii,.rali..n. in vi.'W of the .lens-ity ,.f th,. adlu-sions an, I
ditlieiilly ..f s,.i.arati,m. it was .•oiisid,.red a.h isah)e l,> put in a ,lraiiJaf.'..
tube. A la.,al lislnla f,irm,.d hut closed in a \v\\ dar,. and tlie patiem
re,.overed. Some y,.ars hu,.r sli,. marri..,l and has liad chihlnn. 'Jliere
lias l),.,.n no further nianif,slaIioii .il lnl)(.|. 1...

An.>lh..r ahs... >s, th.. .an-., lor wliicli was .ilis.ni,.. whilst th..
localisation of th" pus was ,lilli,.nll, was ih«- folhiwinn :

K. AV. 1!., a man ,d ;!;{. Wii.s admit ic.l "A" „u .)n|v 12 and left Sei)-
lemher 111. lOl;].

rali,.iit. who was lorim'rly m th,. army. I,.fi lliina six years ajro.
Whilst there he had malaria and an attack ,.f ,ianndi,.e. but iiot dvsen-
tery. He also contracted syphilis, for which he nnderweut two yean*'
trf.at incut.

~)!Lilie9t£.W.l«.'jr*«! ^LsJSBSSr-^iH

"''■'"•:i! .\F!F)OMIX.\K sriMTHATFoNs |.-,l

r.::.:''i::;:;-:::x;i:,r'"''"^

....■ h:''™! '■:■;::::*;::':::.!;.'; '^'-s^ '^"•- r ^-''""- --

In.nMh.. loM.tl. nl.,..J „, • i , ', ,"'" '"'I"""' <l"l>-ss oxtemU

'->- ' i.i!- 1- ;:;.' :; ''"^x: ';:^.; ;i,,:r'''' '"-■«'" --^ -'

IMwi. Ji,.|n„.l „v..r Hi.. n,.|ii h„„. l,..r. ; '" '■""'I'"'""* »f

i::i:'i;..' ^ -^--."":.::.:S;rS-:.!:;::;:-f:

rJ.:;; ::ni.;^;:;:;:r.:;;;;;i.:::;:;, ;;:::;i.r;:::r"'-?'"" ^;-"-- -''"«
r^:r-::-;;;:::;>;;r;:.'^^

a" in.-ision ...ado. Tl.i, , n ^ , , '' ""'•l''^'- w^. ,.ass,..l and then
"fsovoral pints; i, w s , t /. L "•■';,-'""■•'""' '" "'« -^tout

'''••••■■atory on thi;,,„i;::a'''\,.;!V ;:;,,, "" TTr'" "" ''"''^^

e."t:.::!::r;r.i::::.;'Sru;:':iS--"'''- -- - . ^- an

Poljnucl.-ar nfutinpliils

„ ■ , ., ■ • • • •>< P'T r.3Ut.

Small lyinphoi-ytes . . ' ' ' ., '

I-iirfio lymphocjics . ' ' ' ' "j, . " "

I^aixe hyalino rells . , ' ' ' _'|.' ""

C.)aisely jrranular ba,sopi,i'|ic cells ' ' {.y " "

!

! i !

PERFORATION

PAirr III

OF ULCERS or
TRACT

THE DICiESTrVE

In considering the i)erforation of ulcers of tlie dige-tive
tract tliat give rise to the " acute abdomen '" I do not propose
to include those which lake place at the >ite of a malignant
grovth. but only those which are known as ■simple." the
suihlcn giving way of an ulcer of the -tomach or bowel into the
general peritoneal cavity.

Gastric L'ixers.

in the autumn of 1894 Sir Alfred IVarce (iould opened a
discussion at liristol on the surgical treatment of simple
ulcer of the stomach and duodenum and typhoid ulceration
of the ileum and colon. The influence of this debate in (ircat
Britain did a great deal to encourage surgeon- in tlieir treat-
ment of these emergencies, a.id defined the steps of the ojjera-
tion which ar(> essential when one of these ulcers has perforated.
There is no doubt the profession has been much indebted to
that eminent surgeon for the manner in which he brought
forward this subject. At that time the introducer of the
discussion only knew of seven cases of .successful operation
for the closvu'e of the fterforation in a gastric ulcer. At llie
present time the diagnosis and main principles of treatment are
.so well understood that no surprise is exjjressed wlien i-ecoveiy
follows operation. Success is often attained.

The first operation for perforation of a gastric ulcer in
St. Thomas'.s Ho.spital was done in 1S'.>2. This was not
successful, but in August, 18!t(), a success was obtained for the
first time. Forty-nine ca.ses had bi-en submitted to operation
up to 1904, the ulcer being treated by suture and the ])eritoneum
washed out : 58- 1 per cent, recovered. The average tiin<-

im;i{|-()|{ati().\ (h- I L( Kits. F)i(;i;sTi\i: ti;\(t

I :.:{

in (I,,. M„-...>,f„| ,,,..., , al )K„l(.Ia,.M.,l I,. Uv,.,, p.-,fnr.-,.inn .m.l

0|HTati..n wa, -! hmn- ; in the fal,,l .um.. ;!-.•. |„,ur.

IIm; .v>nlt. of n,u.rat,on m tl„. >,.,.„„.| l.alf nf tl,,. im.,,,,,!

incjitiiiiicd aiv l..tt,t iliaii in llic

<irst. ('aM> iuf rtci.itrjiM'd and

xiit inl.. h.,.|iifal car/icr. and

o|)cra1i(.n i> m,.n. ,|ui<kly and

Miicly |)citiiiini d.

niiiiiiL; the year I '.I In tht-
o|)(Tati\.. nidilahty after' ^nlurr
of ixTt'oratrd jra^tric ulcor** wa>
three nut (f fouiteen ..r L'l per
<-fnt. In all tlie anl.iior surface
w.is alVected. and 'he perforation I'l
Mas eloM(| -with lit lire-. The
«aii>e of death in the tiirei' ca-ex
wliieh did not recover was p.riloniii-. ixrisplenie ab-ee-s
and gastric haniorrha-re. Three caM- Mhi.ii Mvre admitted

■• -■■;. Al'lllc i'cl|iil-:iti-.!; nf ;i

(h.-rvir l-U,v ,.v St. •|1|,,,„;,..V^

ri(.. Ii4.^ .-rnn,m-h rcit,„:,ti„i,.. I)i,,^.n„n tn illu>ti;,(,. ,„„<t
'\uuTl '""l ';•" ';' '''■'■'"■;'ti"M. The dark circles HMli.-.tc
Antcii.n. ami th.- rk-,n- cml.> l-ustoii-.r, l'..if.,i»ti.,Ms.

too late for opi'iation died from general i)erit(,niti.-.. I'.l(»;{-lttl2
uiclusive IK; .Uses, witli 7(» cures and 40 deatlis.

Mir

^^■

H!','

if.' ..

!.-)»

TllK ACITK AI',J)(>.MI:N

1 1

uiulir :{() years of ugc) the symptmus Aviiicli arc LTotiixd uiidcr
llif term " iicritoniMii " arc uMially v<ty marked, th.- gulden
oiiM-t of pain oau>iiij,' signs (.f (li>tr.>, wiiich arc iiiiinJ>lnKalilc.
'J'licrc is considerable variation a~ rcL'ard- ihr aniumit nf shock :
fonictinies if is so excessive that rnithinji can -iue the patient.
Shock is followed by <'oMapse. and the patient may die in a
few hours without rc-poiiH' |o medical treatment. '

lutliciiutiiniiiol l!l(i.-, ;i yirl \\iisii.linillc.|-X- „illi:i hiM.iiy..l sii.ldcu
soizurc ..f pain hi \\„- oujcii ul llic ^lnliiilcli xi ^.-veic III II »lic mmimiiiciI
"lit, aiul hMil lo lie ciiined Iihiik' Iioiii I he lr;iiii Iroiii \\l i.h vh,. ||;„1 just
Uliv'htc.l. Wli.ii .MTU ill Ihr lin^pilill liiih iiii hoin IjiKr Ihr illimuo-JH
o( ;;a>Iiic iMTliMiilioii «ii> .■.mlii nicd. Inn I he -lalc <il >li..ck w";is m.
prolouml tlial the iiiii.nI vi(i(.n.u> tnal inciil. lii.liMJiiii; ^aljiie iiiliisiou
into tlu! veins, liiih'd to ovcrcoinc this, anil the piiii.ni diiil within six
hours. She was (jniii- mininscioiis. ni.iili- no loi-ianrc to aluloiniinil
o.xiiininalion nor tliil site eoiniilain ol pain. I h.iv was a larue jiciloia-
tion aliont the size ol a penny in the anterior wall ol the stomach near
tlie pylom.s. .\ eiliiolls laet. noteil at the neeiopsv. was the piexnee
ot extensive ^a.> is eiii|ihysenia ol the ImhIv a lew hours alter ileal li.

As a rule the patient rallies finin the -hock, and utlier
symptoms dexclop which resemble those met with in perfora-
tions of other j)arts of the dio,.,tive tract. In gastric and
duodenal cases, perhaps more than in others, the previous
bistory is important, esjiecially if morphine has been given
recently to relieve pain. It is not wrong to give jiiorphine when
tlic diagnosis has been matle and the course of action ilecided
upon, but there must be no subse(juent going biwk because the
patient "" a|)pears better."

In a large percentage there is vomiting soon after the
j)erforation iias occurred, but the ab.scncc of vomiting is not
against the diagnosis of i)erforation.

Probably there is no form of the acuti- abdomen in which
there is a greater amount c*" iluid to be found free in the
peritoneum. At operation, only a few hours after the onset
of symi)toms has been noted, one has been surpr^ -d to lind
the Hanks and pelvis quite full of a thin greenisi ;id, acid
and sour-smelling. This statement ajjplies to casi a which
the stc ach was comparatively empty at the time, as well as
to thoM' iji which the peiforation occurred soon after a large
meal. Much of it is doubtless of a i)rotective ciiaracter,
thrown out from the peritoneum covering the bowels and

im:mf<h5.\ti(».\ (,|.- iL* kijs DrcjKsTivi: tract i.-.

omcnt.mi ii, r,.,,,,,,.. i.. ||„. urilati,,,, nf ihr ...i.l . nn(.-al> .,f tli.-

sU>nuu\. In ,h,. n.,,...., i, n>..,„l.|... ,.,.v ,.I...„K. ,1... ..,.„.

•Iition Nvl„..|. ol„ain. ..on aft.r f 1... m..I.I..m n.,.tu.v i.f tlu- wall

'> an a ..•..,.. |,v,lati.| ,„■ .„|„,. ..v^t. wIht.. fl,.. ,..„,,...! Ilui.l

lli">(K the |ii'nluiMiiiii.

I!i;:i.lily nf .l... rr-.i ,„„.,.|.., i,, .!,.. ..,,,,..,• part of ,!„' ah.iom,-,,

will l.r ,.,■....,„. ^n,^ j,,,,,! f,., ,■„.... i„ ,1... ..pi^aMri,. n,-!..,,

I" any <a>.. wh.r,. ,|,..,,. is a .lilluultv in .iiauM...>i.s brtw..,..
" |H>orat,.,| .a.tri.. „|,..,. „„l ,„ „,,„„ .u,,.,,,. ,„,.i,„„j,j^
s.'-..n,lary t.. a ;;an^Mvn,.„. ap,M.n,lix. ,1... (..vm.,,,.. of nunh
»n.,. ||„„|. a> .l,.t.T,ni„...| l,v p..n.„.,iun wi.hin .t f.u l,n„r.
att.Tllw.-,.mnM.nn,n,,„ ..f >yM,ptom.. .houM .ummh.! a Mron^^

••ann.jr ,Muar.i> tl,.. >„„na.l. a> tl... h..- of tl„. I.^ion whi.h

l'a> -auM.,! ,i„. ill,,...,. A lyn.panitu. n.,.,. ..vt tl,.. liv.-r

r.-gi..n m an al.,l,,n...n ul,i,|, i, ,„„ .list,,,.!,.,! ,„av l„. an i, ,•.

•"'" ;""'''>'""al pn,„f. an.! i> ,,„, intn..,u,.nt iV .,l,M.rx.-.l i„

jiHstr,,. p..,torafi,.M. m„„. affr ||„. Mi.hl.-n ..n^.t'.-f pain ||,

al.M'M..,., h.,u,.v,.r. nuof not l,,- ,v«ar.U..I a. a ivaM.,, )„r p,„,.

("""'1^' ..p..rati.,n in a r-.i.r ..tluTwis,. .allinu f,„. i, |, ,,„' ,„„

[•••.■Mut m tl,.. f,.ll.,un,j: in>tan,.,. .,f lar... p..,i,„atiun. i„ wLu^h

•"■ '^;;'"'';'" "<•<■'"•.■<.,! altlM.n^rh H... pati..nt ua. .nul-.r ,.x,.,.p.

i"-.allya,|vanta,u..,.u. .■..n.iitinnsth.. -ton.a.l, hav in« l,a.| iv' t
ror two (lavs.

A Kio..in ui:,..l 4.-,. was a.li.utl...l "X- „„ S.-piouilMr .'{.i Ji.(.4 with

ran;:'.::: :../;:' ""^'r' ^' •""- -'•"■•-" -•-- •-> '-

1J;»4, 1.0 .mun.l a la,«,. a,n„un. .,1 l,|...,.l. whi.-h w.,s .,„it.. I,).;^,;

Uheu ud.a„,..,l l„. was s„i,V,„.. a «.....! il,.al f„„„ ,,«(,. ;„ ,„.. ..„i.
.as.,,c ,..g.„n. and was ol.l,>.l ,., li.. .„, „„. j,,, „.,,,' -,.,,, J „ , . ,
^^a.s ,u,r,„al „. appearand,., an.l w..]. ,1,.. ,.v....,.,i„„ ,.f ,..,.,1,.,. ,.1 ,

<I.;,i;;wtniMn Wiw witlio-:t ..via..,,,... „f ,ii.,.. ... i. '""""■'-"ill"'
•"Kil,l..,„k....p.lowun„lk, •"• "'■ ""■' -'-"—

J)..rm. tl... nevt lew .lay, I,.. .■on,plai„...l a. .un.s „f ,1,.. .,.,,.„. ,,„„
ami ho f.H,a..Ua....ns w..,.. ,..,,,.,,..,1 ,„, ,,„ „.„.,, v,.,,,,,!,,.. • i

o^u„.a .u ,„t....vals. on ...., ,. ,, „ „,. „.„,,,„, ,:. ' -„;

i..-clall.....l,n;:ai.d-iv.. .a.thin-hvih,. i„„i,lh

At 1' a.m „u ih.. i'4th ho ha.l a s,.von. a.laok ..f pai... no.-pirv,! v..,v
fiooly. and l.m pulso lo.so to 120 ' ' '^

Wlu-n soon with l.r. .Mackenzio twelve hour, later ho was ovulentlv
suffermg acutely. Lying on his back, wuh head and ,sh....lde.'; ra\l' .1

I An

IHK .\( ITK AIMxi.MKN

i I

i!
If

11

it

ho lookfil |»ale, uj{it;it*'d, and iiit<'ii.'<i'l y aiivuMis, wliil-'t Iim fuct- uiul Iiid'
lii-ail wci't; covt'icd Willi '<vv)-ut. Hit ii'>|iiiatiiiii^ wnv Imrriid. |ii;iiitiil,
hIiuIIow, ulid irirguliir, tin- piiKi' rii|iiil, and Ih' riiiii|ilaiii<'d iimrli ol puiii
ill tlut alidiiiiit'ii ; lit) wan iiiialili' to taki- a dri'p hicatli on ari'oiiiit nl tli<-
pain, and i>n rxaininatinu ot tlic alidoinm it did iioi ninvi' iiiin-li with
n-^piraiion. It was gfiit'ially Ifiidcr. rigid, ami lallu'r di^tiMidtd. 'I In-
liM'i' diiliirM4 hail not di-'appt'iM'cd : tlii'ic wat diiliii''>-4 in liotli llaiik^,
also acros^t Iho iu\v<'i' alidmni'ii al><>\<' ilic |iiilii'<.. lie liatl vnniitt'd.
'I'llf It'lllpriatlllti wan ItMltl .

iipciatioii was porlni nii'd a< ^nun a* pii>>ilili'. On oiti'iiin^; (he
p<'i'itoiii'iini iIk-i'i) wuh a lliiw ul ^r<'<'iij>li tliin -.iiiir^iiK'llinv' lliiid. 'I lie
Kloniarli was sonii'wliat adluit'iil tn tlic niidn ^nlla<'^ i>l the liver, and
wlii'ii I hey were separated liy the liiiyer there wa-* a mish of free pan.
'I'he liiijjer Wii-s passed to the pyloiie region at onee heeaiise of the dia){-
nosiH of perforation ol nieer in that situation, made liy ])r. .Maekenxie.
\ sharply-eiit ulcer, lai);e enoii;;li to admit the foielinjii-r. Was found on
the anterior siirfiiee of the pyloiie I'lid of the sloniaeh. The slomaeh
wall round this peiforalion Wius iiiurh lliirkeiied. The hole was elosed
with interru|ited suture.-.. 'Ilie peritoneal ia\ily appeared to lie tilled
with tlie greenish fluid, there lieiliy: larire eolieeliiuis in the pelvis, the
flanks. tli<> Nuhhepalie and splenie regions. A eounter-openiii^ was
iiiadu ahove the puhes and the ahdomeii lljoroui:lily washed out with
normal saline. The intestines were not iniieli distended.

The deposit of lyin)ili was limited to iht- parts around tlie perforat ion.
Xoinial saline to tin; amount of two )>iiits was |ia»ed into the median
hasilie vein during the o|)eration. as tlie pul>e liecame very feelile and
ia|)id. The stomach was a ;,'ood deal dilated. Tlie upper wound was
closed and a j;lass drain |)laeeil in the lower one. Ueeovery was slow
hut satisfactory, and he left on jiecemher 7. l!Mt4, for his home in
l»e\oiisliire. 'I'he induration fiii'ioiiiidiiii,' the ulcer coinpelied the
ill fold in;; of an iniisnal amount of stomach wall.

I do not tliiiiU authors of t( xt iiooUs. wlini writiiii: of tlic
tUaguosis of jj;astrii' ju'ifoiatioiis, liavf |)ai<l Nutlicii'iit atti'iition
to tilt' valuable iiifoiiiiatioii to he oUtaiiUMl by percussion.
In nearly every case the aiiiotuit of free fluid |)resent is eon-
!-iderable. and if e,.u be defeeted <iuite early, aeeuiiiulating
in till" llaiiUs. Jt should not be possible for any ease of acute
abdoiniiial paifi to be introduced to the singeon with the
])eritoiieuni full of fluid and no stateiiu'iit of its presence made.
This excess of fluid helps us to place out of court such con-
ditions as pneuiuonia. diaphraijmatie ])lcuri>y. thrombosis of
tiie superior mesenteric vi'iit. various kinds of poisoning, and
acute ililatatioti of the stomach. There are four or five states
of the acute abdomen in which we get ati excess of fluid —
peiforated gastric (or duoileiud) ulcer, rupture of an abscess

PKHFOKATIOX OF IL* KHs. DKiKsTIVK TK \( I' i .7

(Usually a|i|n'ii(li( iilai). rupturf nt' iMiiuitcmic tcrtatii.ii.
ruplurcil |iyi> ^al|lill\, nr tlic luptuic nf a larsic rv>t. .\^ a
rare occuirtiicc it i^ mim atHi llu' ruplun' ot u lar«_'«- ciniivfiiia
of the appfiidix. A iii«f in whiih tlicri' is rft-Min tn »u-pi(t
gastric pcrt'oraliiiii, hut almut ulucli ynii arr tin' >iiic, -<lii>iil<l
he caictully rxiiiniiicd for the ^i^fiis of lire tluiil iid itnlv at tlic
tiiiif wlicii tiist ~<cn. Iiul cNcfy ln.iir atlcrw.inl-, fi.r there
arcftw'ciiicrpticK ~ that liil .-r i( pay prniupt -utj.')' il atlrutioii.
('iiiitra>t With the ca-i' jii-l di'^inhid the follow iii'_' ami tli.
iinportaiicc of what I have -aid will l»c cs idttil :

A mii>i-, ai;<'l -i». wn- adimir.d <iii N.ivciiiIm'i- I'M. lHUt. luiviiu; licoii
x'lit U|> liy I>i'. Lurk, oi I ■ \lii iilije. fill- pciliiralrd jrasliir iilrer.

She liiiii siiUViimI fniiii very ImiI iii<htr«'^i i<>ii at uilcrviil-t (hiiiiii; the
|iast thif(« iiioallis. aiiil. Iiuviiii; Ixwn on iiiirlit ilaiv, wa-t in lied on tlip
iUlli in the atlcniooii. wlicii -.ln' IimiI a suililcli scmtc pain iii llic t|iij.M,s.
tiiuiu. Slic wa.t vci y sick. Ilin |)aia was holliT on ilio L'Tili ainl l'siIi,
but she si ill lia>l tfiulcriii'^s.

A hoiiiowlial clilofolir •vMMiaii wiih /lii^liod iliui ks, ami w.lliout any
hijru of aiixit.'ty. A [miU.- <>i Ii>4. ami riwiMratioiis, 2« ; ti-niiicriiluiK,
liin'. she (•(iiiipl.iiiK'il <«| -citiic paiii iu ilit< alMloincii. liiit of iiu jjifut
si'voiily, ami the ^irkiicNs had no) nciinud. Ilcr ;r»'ii<Tal loudilion was
jfood. Till' alidcitiifii was MMiirwIiat dislfiidid, }.'' "'Tally t'lid.r. hat
mil very inaiki'dly m>, yrt the musrlrs wire ii;;id, and iIi.tc was sinfiini;
dulii*;ss in the Hanks. 'I'lic li)n;.'ii(' was furred and the howils conrmcd.
'i'lu're was a diltVicnco of o|iinion as to tin ahscnco of liver diilncss. Imt
tlio diai,'nosis was •• a xniall |>erforation of tlie anterior wall of the
Htoinacli and (•on>ideralile elTusion in tin; |"ritoneuni." It «;ts some-
what dillienlt to convinre the patient that she requiii il inunediale
operation, heeanse she did not l-el very ill.

It WiH not eas\ to lind the |>erfoial ion, for no jras <.r Ihliil e>caped
dnrinf: the, seareh, and il was only hy evaniinaiion of a small patch ot
lymph witli a ninall prolie that it could lie found: even then il was not
pii-silde to forci- fluid thiduuli it from williiti the stoiuaeli l>y any kind
of pressure. 'I'hi- openin;j was ni a iialch of thickmini; ahoiit t lie size
of a llorin to the h'fl of the middle line near the lesser curvature and w.is
covered in hy interrupted I^einlx'tt sutures. The Huid in the ).'<'m'ral
peritoneal cavity was i)uriilent, especially in the (wlvis. and ireneraHy
ditl'iised. hut <'oiilained no traces of food. It %vas washed awav witji
Kteriliseil saline, I hroujrh a drain in a >u])ralMihtc opci,in: I'lio iippei
optMiiiiu' was closed; a draina;:e tuhc was left in |)ou,'la-s pouch.
Uninterrupted reeoTcry.

The operation for poiforalioii of a gii>trie nher may be
divided into thin- parts : —

(1) The abdominal incisions : (2) the liiidiiiii and tfcatincnt
of the ulcer ; (.'{) the cleansing of the peritoneum.

I il

■«n^^

§n

n

\M

THK \< ITK AIMMiMKN

5 L

In |)rc|t;iiatinii for tlic ()|MTiitiim it niiiy hv \u »iirv to <l<i

a jifcat <l(iil to •■..iiili.il llic ^Ii.mK .iml l»iiim tlir patinit iiiti)
II (•(•iidition to hiar tin- iv(|iiin(| tii.itii|MiKitioii Tlic u>iial
prfpanitioii of tlir -km «itli ioiIum' i- ii.l\ i-;i)»li'. aiul tin-
Mit^ifoii mil-) niiiiiiilMT to hiivf tlif hair of the aliiloiiiin and
>ii|>ni|iiihic KL'i.iii -Iia\<«| Thi- piirt of tin- intparation i,
upi to he ovci looked. I'lic ii|)|»ir iiici-ioii i- mad)- tir-t. -Ixnild
he ahoiit < in. lie- or iin.rc in Icnjitli. and i- made in the cpijjii-.
liiiiin. from the left co-to xiphoid an^lr (h.wnwanl^ to the
left of the middle line. Uefnre the peritoneum i- opened it
may liiiiue irreniilarl> into the wimiihI from the ;;a- which has
eolleeted behind it. whieh hllliliie- up when tin- la\er is
inei-ed. There may lie none if the ea-e i- an earlv one and
the perforation -mall. Thi- amount of lluid i- very variable,
u.siially of a mawkish mihII from ^a-trie jiiiee. and a< id in
reuition ; there are freipieiitly particle- uf halfdiue-lcd f(.,)d
ill it. according to the -i/.e of the perforation, the character
of the last meal, and the time which ha> elap-cd -inee it was

taken. In ca-e- where there is much lluid it is a j: I plan

to pas- the hand 1 .roiijih the upper wound to the under siu-face
of thi' hypo;;a-tri. re;;ion. cut down on it. and |)lac<' a tiilte in
the pelvis : the tliiid can then run away under an aseptic pad
whilst the neces-ary manipulation i.f the -lomach i- hcin^r
carried on.

.\s the pertoration is mo>t commonly on tli<' anterior -iiiface
near the les>er curvature, this i- the part wiiich -hould he
c.vamined in the first i)lace. The stomach slnaild ite (irmlv
but gently pulled downwards, wliil-t tlx' lluid is moppeil
away as it comes from the opeiiin;:. that already in the peri-
toneum being kept )»ack and partly ab-orbed with wide -trips
of gauze. Sometimes the openiny i- temporarily idocked bv
a particle of food. l»ut a- a rule there is an increasing How (if
lluid with bub1)les of ga- as a result of the increased tension
when it is pulled upon.

If the opening is small or concealod ))y lymph, a mor(>
eareful search may l)e necessary, but the injection of air into
the .stomach by means of an (esophageal tube as an aid to
localisation is not either advisable or necessary. .Abnormal
redness of the surface, the presc-nee of a patch of lymph, or
the di.scnvery of a hard plaque of tissue wb.on the j)crforation

PERFOHATFox op ihcKKs, i>r(;f:sTrvi: ti; \ t i.v..

is sniftll, iniiy in.liiiit.- it. Any rii. nt fi.llM.si,,ii> bifw.'ou tlie

stoiUiKl. iitul livn -iM.uld li |.ivnif..l ami fi.l.U ..|,,ri..l niu

If the viomacli i- iitiirh (iilat.d, liliinu up tlir v\ >irir i. yioii.

it slionl.l l.r «'iii|>tiiM| ritliiT IhitMi'^'h th. iMifuriii or ihn.iiL'li

ail <f,|.hjmc,tl full.'. If (liMtiid.d inlc^iiiir raiiM'. liillinilu
il nmy In- |miirlmr.l with u tr.M'iiar or fh.- poitit ..f a knif,. anil

'I'lif ^iitiin-, til I !(■-<• till'

the piirictiirc ci..-.,! u-i1ii ii -tilcl

pcrfoiatioii slioiihl be of

>iik iritciiiipt'il. ^riii

muxiiliir. aiKJ pa--((|

iiftiT the ini'lliiKi III"

Lcmbcrt. If t«c.i|p,ii:.;

coiitciits caUM- ( nifi.ii -

ras>iiinit a >tit(li m t vv. .

may bi- iiix-rtcd n r. i-

tb«' opciiiiij^. A^ .1 rule

N(i. I >ilk i^ >ali>fa(tMi \

for the >iitiiii'^. Imt if tlic

.xloiiiiuli wail i> softened

No. 2 >lioul(l be U-ed. I

have f<»und a siiijile low

of tlicse siillieieiit. but

thi-y .should iKiietiate a-

deeply as the -ulinuicoii-^

layer and extend well

beyond the perforation.

As a rule they >hoiild be

passe<l from side to >ide.

cspeciallv in the re<'ioM

of the iiyloru-. to avoid

narrowing' of the outlet.

All should be inserted

before they are tied, and if tlier*- is any doubt of their hold on the

stomach wall reinforcinj^ >utures .-hould be put over them. In

small perforation^ a continuous J.embcrt suture mav be u>ed :

whenever this is fea-ible the suturing should be "performed

with the viscus outside the wound, resting on sterilised gauze

moistened with warm saline. When the perforation is in a

fixed part, .suturing must bo done with the stomach in situ ;

here tlio Wound nmst be well oi)ened out witi> reiractors, and

Fi.

'. -•/ I'l'il'Miiiti.in
iii'dti'ii ••{ -iitiiii
inurli tliickc'iiiiiL;'
.■^utiiM'- l.rini;ii._'
lnil>rul;ii' fi--n,
nut t''ii-ii>n.

if liii-trii' l'j,'(

■ ulull' til' !.■ 1-

..f tin' l.;i-.. n\

■■< ridj:.. ,.| -,.,,,'-

■"— till' nil i'i- with-

KiO

THF<: \(VTE ABD<)>rKX

J

'

P f

? i

it may he found necessary to cut the left rectus, althougli
this should not lie lif,'htly (h.iie. Where tlii-re is an opening
in an in(hirated area wliieh will not hold stitches you must
hrin<:; a fold of stomach over it from the cardiac side anil suture
that securely to the parts beyond the induration.

When the condition of the |)atient. the position of fho
ulcer, or tlu^ larj^e area of induration makes it impossible
to close the perforation as advised, there are various courses
open to the o|)eralor.

A drii.ina:,re tube may l)e pa-ed down to the opening and
gauze packing place<l round it for >Mrne thirly-si.x liours. It

may be po>-,iI>le to cover the opening by suturing M)me omentum
over if. or the liver may be utilised in this matnier.

A gastrojejunostomy may ])e performed to dimiui.-h the
leakage from the wound, but it mu>t be rcmernbereil that
idthough the amount in the upper ahdomen rnav seem
Mnall. there may be a. considrrahie (piantity of lluid in
the pel\i>.

So far I havopokenof the p<>rforat ion of ulcers on tiie anterior
sui-face of the stomach, for perforation is most eonnnonlv
met with as a complication of the-e anterior ones. 'j'hV
|)o.-teri<.r rarely ix-rforitte into ■ ■(- portion of the peritoneum,
owing to the teiKk^ncy of aunc-ions to form between the
surface of the stomach and the painreas. If the historv of
the ca-e points to ;i, perforation. aii<l none e,in be found on
tile anterior >inface or along the lesser eiu'vatin'e, ym uui>t
cMuniiie the posterior surface. Here there Mill probably be
little lluid present in front (.f the stniii.i.'ii uh,.,! the ahd.Huen
is opened, but search may lev.al s,nali bubbles of gas under
Ih.' p.-ritoiicum as it leaves t|i,. u,vater ciirxalure of the
stomach. This perforation can be attacked 1 liioiigli ~{ I ) the
gasifo hepatic omentum, wiiich readily yields and gives direct
access to the area Usually afVected. or (i>) In tearing lln(ai<iii the
gastr,, ,,,ii,. ..ineiiturn. The nail.. cIiommi will depend on the
dittiiullies (,f 111,, individual i-.im- and the po itmii n( (he ulcer :
III lilan\ the luiite above the stomafh will give the easier access.
TIk' linger pre-sing on the anterior »vall readily brings the
lesion into view.

'I'he following is a case of perforation of an ulcer on tlu^
posterior sinface nf the stomach.

S;^^•,-:r^-f:^,

I'KliFOHATlOX OF VUFMs, |JI(.;ksTI\K Tn.\( T

Kil

Vi "J" ''"';'/,-•'• ''"K^'"-'! iu ii lauii.lry, was MhmtWd -X- January 2
and left on Febniaiy 1(1, lull. .'.i.iiia.^ ^

■Sho -ave a Iiistoi-V ..f Ihiv,, to f,.,.,- y,.^y^ in.lii;,..stion. i.ain ami dw-

;■""""•; •'""='• '"-''■'• "" '!"■ '•'•^MonH .lurin.MlH. pas, tllr... yoars >1...

us had an.,0 attarks ot pain sin.ilar to tho ,„vs..nt. and has 1,;.,. ill iu
'"■<! I... son.o tiu.. aftcnvanls. Dunu^' tho last thtv.. wo.ks sho has had
;ho,o pant than usual and has " had the wind " had! v. About ■• p n,
».>.■ day 1... lore ad.uis.sion the pain was so bad that it doubh.d her np
and she had to ,.. to bed. There was n.ueh shoek. She did not vo.u.l
until the niornui- oi admission ; and the syniptoius when sh

were probably inllueueed by .uoiplune, which hud been given before lie
journey to In.spital. *'

eanie in
r

She wa'i drowsy lud Jier j;eii
^inal'

,, . ,, '""'I '•X|>i<'s>ion placid; the pui.ils were

1 ulse. IiH; temperature, lol-.i . The loujrue was very drv and

, : , • , ' '"' "'"1"""''\ was movinj: , ly. was -.nerally distended and

.r. . T'' ^"^"•''""■'>' "'"'l'''- "" "V'-. On per.-ussion there was an

a.ea ol .lulness m the h-l, flank below the sp n, whi.h shifted on

m..venient. Iriction .-ould be heard over the left chest in ln.nl • liver
<l" "OSS present at the side. On makiujr an incision over the stomach
alillle;casescap..d,but not much fluid. Nothinj; abnormal was seen on
the anlerior surface, bu, as fluid with Hal es in ,t and small bubbles of
«as was .om.nf: tlirou;.'li a small J-, 'e in the Kastrocolic omentum this

MM'.nn^ was enlarged and the ,■ isie.! ,, surface exph.red. .V p. .fora-
fimi was louu.l near liie less,.r .•urvalure towards tin- pvlonc eii.l • it;
was surrounded by an indurated aiva the si/.e of a sixpence. It wa.
shut in by nn.ans of two rows of silk LcnberL sutures. Th.. lesser
sac was washed out as w -11 as the fieneial cavil v
one boil

a sixpence
siiliires. 'i'he le.
ind lubes were loft in,

one beinu- passed into the lesser sac. the other into Douglass pou.di
( ouvalesceuce was retarded by an attack of pneumonia in I he left Inn-
Ihero was .oiue .lischai-e of a puialent naiure from the lo«,.r wound
ii<r a iortiiii,'ht.

Wo have placed considerable .stress on the iiee.l for iwirefiil
siitiiriiig ; it is now necessary to emphasise 1 he need for tlioroiK'h
treatment of the peritoneum. The pelvis must always be
examiiu'd. for although the amount of lluid is small in the
upper abdomen, there may be a considerable accumulation
111 the pelvis. Irrigation is required in most cases of gastric
J)erforat.on, because of the partly -digested food producte
which have escaped and the irritating effect of the lluid with
which they are mixed. Without this it is almost impossibj,.
to get rid of the various particles Avhicli have l)cen swept into
the outlying parts of the peritoneum. The lluid used should
bo sterilisetl saline (.sodium chloride -,j,, boiled water Oj ) at a
temperalure of 103^ If no irrigator is at hand a glass tube,
or the eiul of an ccsophagus tube, attached to in.liarubber

A \.

ar

IBi

THE ACUTE ABDOMEN

tubing (rc'fi'iitly boiled) arrangi-tl as a sy[)lion or attaclii'il
to a fiuim-l, Avill siTvr the j)urj)osc. Failing tb»>c an orilinaiy
Higginson syiiiigc worked by an a>sistant, wliil.-t tlic surgeon
pertorms tlie needful numipulation of the ])arts. If. liowever,
the ease is ([uite early and the extravasation limited, iiriga-
tion may be unneeessary and a limited eieansing by means of
moist swabs snlliee, but as a rule, in my opinion, a eond)ina-
tion t)f the two is retiuired if there are many food particles
in ihe peritoneum. Try to eleanse the peritoneum from above
downwards, and make tertain that the hepatic and splenic
regions are ck'ared early ; the amount of fluid in tliose parts
is often very large, and trouble may arise there from se])tic
infection after the operation.

Somi- jiints of saline will be n-cjuired and irrigation should
be continued until the iiuid eonus aAvay clear. 'J'here is no
need to dry the peritoneum ; it does good to leave clear fluid
of this nature to l)e absorbed. The necessity for drainage
depends upon the ])articular ease : if operation has been
early, and the amount of extravasation is small and limited,
the abdominal wound may be closed ; in the majtjrity of cases
it will be advisable to drain.

The 'Fowler positiori" should be adopted as soon as the
j)atient has recovered from the ana'sthetic.

Before the patient k'ave. the operation table a rectal injec-
tion of sterilised saline with an ounce of brandy should l)e
given, and the use of continuous saline ptr reclinn should be
commenced a short time afterwards.

There is no objection to the administration of >i])s of tepid
watiT by the nu)Uth. but nothing else should bi' given for the
fn>t forty-eigiit hours. ]f there is much complaint of j)ain,
and the t)atient is mtv rt'stless or unable to sleep, a sid)-
eutaneous injection of morphine may be given, but it is to be
avoided if |)os-ible.

The treatment above advised is best calculated to prevei: :
the more common cau-es of death after tlii> arrident —
peritonitis, shock, subdiaphragmatic ab-<fss. Thei'c are
iwo comj)lications which cannot be guaitled asiaiiist : —
0) J'eiforation of a seconil ulcer, stated l>v Kinney to be
present in Ji> per cent, of the ca-es. Tlie occurrence of
it seiond perforation in the same ulcer when it is large.

mm^ufwm

PKHFOHATIOX OF rU'ERs, DICKSTIVK TI5A(T ,,;,
(^)^ Ma.n..nl.ag,. „uy occur fro.u tl.c >a,nc ul-cr, or unotluT

.lu > M„al iHTtoratiMU so tl.at only a little llui.l ,..,.u,k.s
wln..h may In- M-allcl ufV by adhesion.:. This Tn.v In,,,'

I" •..alio,,. ||„. al)M.,.ss may jinulually rstvnd if un..va.,.<l
-"'•■v.-.uually attain a large si... Jf in connection
Wuo. end ,.e..to,.ation. ,.i,. n.ay appear in the cli!:. ;^.:
Sho Id th..y rupture n.to th,. general p.-rituneal cavitv ll,;
.-ni, VV.II p,ohal,iy he fatal, as it is almost in.possihie o 11 '
"I- .solate. the leaking point (see Pen.u.fric Msa.., ^ h,"''

rKKKOR.VTIO.NS UF DloDKNAL I'u ER.s.

yi^iu an.l ,s not always possible to diagnose .h,. one fnmi
''- ""'7'- ' 'H'.v an- far n.ore eonnnon in n.ales over :in

n. K-nndes. hut ^Ir. .1. W. StruthersNKul to openuUV h s
-riorat.on umler the age of .0 in tw,. instanced and onlv
-!. Mas a t..male. Osier says they may be distinguished v 1
followmg dehinte cliaracters ■— = '^ "\\ im

::;'S;.;r;:z^v--d.«as.ra.^^^

rufortu.iately, in many cases, there is no history of local oai.i
precechng the attack. ■ ''"'^

It is advisable to speak of this variety of p.-rforation
s<;iurat,-ly from the gastric, because it is often hi h^h 7
;-n«uish perforations of these ulcers from'^: f , ^
<> the appen.hx A.nh peritonitis, especially if ,he apnen.liv ," •
Situate,! to tlu. outer side of the cecum. oHu.s ue;^'' ,. ^
't^ proper positio.i in the iliac regicm '^

When the pc-rforation is that of an ulcer of the stonuu-h
tlu- syn,pt.m.s are those of a general peritoneal invasion ; wh 'u

: I

fin:

J !

I » ! < '

i

ii

164

•rilK ACITK ABDOMHX

till' pciforiUioii is in (lie duodrmiin, tlit' I'Miipiiii,' fluid, which
rarely cuiituiiis soliil jKirticles, Ihnvs chnvii the right side,
external to the eolon, into the j)el\ is. In these cases, there-
fore, the resend)lanee of the attack to one of aeiile perforative
appendicitis is very close, and a mistake in diagnosis has been
made by the most experienced. .Mr. Struthers,' in relating
his series of 27 ea.sos. says that in three of them the i)ain
was referred ehielly to the right iliac fossa, and the ma.xinium
teiuh'rness and resistance was below the umbihcus on the
right side, but the tempi'iature and pulse-rate wert- not
markedly raised.

Moynihan states that in ~)l eases collected by him a correct
diagnosis was only made in two, whereas the primary incision
was made over the appendix in 19.

At the time of operation the apj)endix nuiy be found
surrounded b\ an area of uitlamed peritoneum, and may be
itself .so intlamed that the surgeon is misled. It would be
well, therefore, always to examine the duodenum in its first
part, when disease of the ap|)endix is not manifested by gross
naked-i've change, such as gangrene or perforation.

Do not forget to examine the pelvis for extravasuted fluid ;
failure to do so in any case of perforation may prove fatal,
whether the ulcer be of the stomach (anterior or posterior
.surface) or other part of the digestive tract.

The following ease is typical : —

A c'iibniun. Ufrcd ;i!l, \v;is iuliuitttMl -X- <iii ■luiu' i'.i. I'.tOT, I'oiiiplaiuiiij;
of luiifli pain ill tlic alKloiacii. He Iiail t-utTcicd froia \<nin iu tiie
<'|>ii;iistiiuiii lor ten ycnis. coiniiiir on aboill aa lioui' after food : also
from a fceliiij: of distcusiou ami tlatiilciicc. full liad never had any
voiiiilinj;. 'fiie atlacks liad come " off and on." Six weeks l)efore
a<lnii>sion he liad nolieed tlial liis motions were lilaek. At midniirht
on .lune 12 he had taken a ii\n^s of hi'er, the diiiikiny of which was
foUowed immediately hy vioh'iit ])ain in tlie ahdoinen. 'This was
esju'cially severe over the jmhes. He vomited one and a lialf horns
afterwards, was in jireat pain all night, and liad const ant acliing jiaiii
in llie riglit shoulder.

On admission he was in a condition of collapse, with a jinlse of 14i)
and temiieratnre of it<i . 'I'lierc was marked tenderness all over, liiit
more ('Specially down tlie right side, and duliiess in both (lanks. The
muscles ol the ahdomen were very tense. Sixteen and a half hours
after perforation an epigastric incision gave exit to a giish of fluid and
grts. wliil.st uuulher incision over tlie hyjiogastric region gave freedom

' Kdinburgh Mcd'co-CUirurgicalfSouicty, Lunot, Vol. 1.. i'J12, p 1371 .

F'KRFORATIOX OF FLfERS. BKiESTIVK TH \( T if..-

''^';;--- -•-•-^- n:":'::::>^:;:;;i;;:;;v:::::!r^

'I'lu-ir was flM> su.I.I,-,, onset of al..lo,ninal pai„ (,vl,i..h is
u>ually Miost s,.v..,v al.ov.. a.ul ,o ,1,,- riuh, of I,,- „, . .

with ,uark...l sl.o,-k, f. llow..,l I.v vonmin. M. 1 '"

Ifnt interval, ,,n, .,... syn.pton.s wln..,rpn' .,'.:;
oa,„.nton„.sM...n.,l..fini.o. BiL-stain.-.l Mui.l n.av V ,^
111 tlicso (•as(-s. and tic sutmvs (of v,, i .in ^ i 'i, ,

i"WL.n..HVn,.th,.dinti.o!;'':i,; ,:^''' :,f;

HiMs. an.l sa|..u. <.,,:.nu.n,..,| at ...ht. I.y tl,.- usnal n„>tl.o,l of
-i"nn,stra.;on ,,>■ rn„n„. Afr. Strutlu-rs .lo,. no, ZlCr
-.at.on n.,nn..l. bu.^ a.lvo.u-s draina,. for tl,. ti.t ^ -

nitn tiK p,-! .s no l.ann ,s .lone l,y niakin^r ,|„. pn.|inn-n-,rv
.."•ision ni tho lo.-c.P al>,ion,..n to oxannno tl... ap ■„ '

d.a....s>s of n.t.stinal ol.tn...tiou has ],...n n.a •. ' „;'

«<.ty. (■xat..n.uultn,.K^^^^^^^ "t .

"gl.t M.I..), an.l tl... nu.ompl,.t,.n(.ss of tlu- ....nstipation n v
si>rv.> t.. pn-vnt tins ,-m,r in most instan...s ' •

ilH- a.lvi>al,lli,y of porfonning a gastro-n,t..ro>ton,v ,n„.,

■ <'o.is,jl..n..l .-h..n..v..,. operation for p..,.fo..at...l gain >
""•'"";^' "I*-- - p,..fonno,l. hut tho num.,..,- of .....in .1 h

i.« IS hn,t..,|. lo ,lo ,t n, some m-o„|,1 h.- to ens,,,... the
'J- . ..f the paf.nt. an.l th,.,-e are few in whieh it ..an
sa,.lt.,he,v.,,nn..l-the,...an.ltl,e„-to.avelif... A ...... -

«;i>-'^t,on ean he pe,fo,.n„..l .ith safety la,,.,-, .honl.l .vn. , 's
■''■""•'xl 't. It is ,he ul..er of ,„. ,,.1,. ,h, ..vl ' ''''"."^;

i-K>st,i,<e,,M.U..a.,t.>e..nt,-aet,..,:tte'- ;;•;.:;••
,- o.a ,on sho. .. nev..,. diminish th.. passage t., ::^h .
. xt It as to ,...n.Ie,- a gast,.o.ent..rosto,ny a ,na„e,. of ,„ „..,-

• t .. pres..nt .by th<.,.e ,;s p,.H.aps a t..n.l..,.,.v to ,Io^^^ -^^
"H. 1. f.... the surg..on natn.-ally wishes to pla,.e J.is pati..nt

n lehestpo.t,.mf..,.e.m,pl..te,v,...v..r^^a,d,hat^i ,

;;; :;V7;;"'7 ^'•"•'' -n .,ep..n,i .:,. th.. ..onlhHo ;

"'"""'*•♦'"; •'•"•"t'-m ..f the inn..ss. and the wav in uh.VI
tlie ana<sthefie is tolerate.l. ■ ''

I

I 1

Kifi

THE Af UTE ABDOMEN

Should tlu' Mirgcoii think it rijilit to pcit'nriii :i trii-tni-
ciilcro-toiiix the antciiof iiK'tluwl will l)c tlic mic clioscn. It
ciin he (iiiickly iK'tformcd ;;ii(l (Iocs not involve ninch <li>tnil»-
aiuT of ])iirts. 'I'hc ilnil^t(»nlosis .-hould he nuuh' toward-; the
pyloric end, and near the jrrcattT curvature of llie -tomacli.
Let the coniniunication between llieni he fully two inchc- in
ieiiflth. and al)out IS inches from the eoinniencenieiit of the

il

H

-i

\-p\l

nj

I'lii. ->'i.~ To lllu^tiiiti' till' itcl.itiiuis iK'twccii .Icjmmiii iiiiil Stniiuirli
in tlic < iiHTatiiiu el' Aiitciinr ( iii-tin- l!ntiTn>tiiiny.

jejunum. The clam|)s should ))e a]>|)lied ol)liquely so tliat the
o])eiun<; slo|)es from the left doAMnxards to the ri^ht, and it is
advisable to a})|)iy the outer suture for some distance al)ove
the inner row to |)revent kinkiny of the !oo]). although the
application of one or two extra sutures to hold the left
extremitv of the curve of the loop in position will answer the
same purj)ose. 1'his anastomosis is peifoinied in a manner
similar to that described under entero-anastomnsis (p. liSO).
]t is not necessary to impress upon the rcatler tlic value of

I'KHF-OHATfoX (»F ([,( KIJS, I)[(;KSTrVK Ti; \( r

lti7

MMiMulai- liui.lity Ml ilw ,i.nfr al),lnm.-n a. a. pinnt llmt a
grave lcsi,,ii has .Mriinvd within. Thi. n^^i.litv is a v.i v
impurtai.t >iui, nf |H.rforati.,.i. th.. alKlnnu-n hcii.- nftrn

hi. Tally as hard a^ a l..,ar<l. and in ihr diaj; i, frn.n ulh,.,-

.Miilr staf.N it nn.sf I.o s,H.,ially look,.,! f.,,- and its variation
Ml ditlcrcnl areas noted.

The acute diseases wliieh are likeiv t., 1,e nii-takrM I'm-
perfoiatinns .,f the slon.aeli and dii.H|..nuHi are nuinlv the
fiillowin;; : —

(1) Arntr /.ounrnllll.'i r(>send)Ies i.eif.)iation of a, "a^iie or
duo<lenal uher very elosely at times ; th.Te i> the same onMt,
with severe pain, voniitintr. ami eollap.e. If this i- .oon
followed l,y e.xmlation into the peritoneal eavitv of a lar-'e
fiuantity of fh.id the resend.lanee is verv L'r.a't. I'Miallv
howover. the pain renniins very intense in t"he"npper al.dom.."n'
diiluess on percussion is patehy, and t lu^iv i. a -eneral superdeial
ten.lerness without very marke.l rijiiditv. .\ Hm- of tempera-
ture IS frcjuent. The patient i- UMially a male Mouf and ovr
middle ajie.

As showinr; the .linieully oeeasionallv .ucounteied the
followint,' ease may he (pioti^d :

A nn.lor.Ml. .liiv.-r. a-f-.l XJ.wms silti,m,„i l,js .,,1, .,„ui.|.. ,„ t ,|„.

larKv .rirkri un.un.ls WMJiinK for a t.-nv. wh..,, )„• w,,^ MMld-niv n.km
Willi a MVPiv paiM ill ll„. „i.|.,r aI..h„M..M ,„„l v.mmii.,! i|.. um

■-"''I"''' ' ll«<'slioM all.l liu.l takrn t.H„l s|„.,tiv U,-U,yr II,. „„' ,

sloii. man. < )„ a.li„i>si„n I w..nl.v.|.,Mr hours ImI,,- I,., was ..vi.hnilv
v,rv 111 siill.'nn- Iron, sovrn- ,,ain and triMlnncv. in il,.. .pi.-aMnr

ivKion; lia.l a iMiLs.-rate tiM. h ni.-l respiration, ;,„.l i.nin..,,,,,,;. ..7

111.- al..loni..n was ,„ovin« l.a.lly. aiol ll,..,v ua. al>iH.ri„;,l n-i^laMr,'.
to pivsMiiv : in a.l.litioii liieiv wms slijiiii .liilii,.>s j,, 1 1„. ||iuk<

<M'.Tanoii was p,.,rornir,l sliorliy atl.M a.hiiis>ioM, l,iil 'ili,. Ih,„l ol

wlii.'li tli.'iv was a lai-.. .|iianlit,v. was 1 .1-s, .,i,„..l, ,„„1 ;,ll,r , -.■ m li

lat n.'.'iosis ol 1 1„. oni.'nl 11.11 was loumk Tlie ali.loin.'ii wa~ « .i^Ih-I 0111
an.l a .Iramase inl..' i.ar|<,.,l olV will, ^a,,,,, „■;,. ,,,.„„„, ,i„«„ ,„ , |,.;
I.annvas tliioii.li an o,Mni,iM. j„ ,)„. oa.M lo-roli.- oniiiil ,i,„. ||.. „,,.
i.'li.-vnl ol Ins pain. Ion ,li,,l su.l,l..nly iho lifil, .lav .,1 illn, .. will,
t.'inp.-ralniv Id.'! , rapiil car.lia.' failiir.- aii.I .liiiriuni

\o tumour eouM !„■ folt before operation. . aniiiiohros na<ii..ii
was positive.

(2) Acute h>lcsth„il Oh.trucliov.-Ahn'i- there i. vomit in-
wiueh eontmuos. eomplete constipation, and parovyMiial
pam. with a peristalsis which can l)e seen or felt. Distuisiua

i(;.s

THK ACITK ABDOMKN

! i

■■ i

\\

soon comos on. Imt lictwccn flu- paroxysms of pain flicic i< no
rijjidity.

In tin- sudtlcn onscf of j,Mll-sf(ino obstruction due to a hir^c
stone in the duodcrnnn. there may he ditliculty for a time,
for the pain is hii,'h ti[) and not aeeonipanied with intestinal
pj-ristalsis. Tliere is no free (luid.

(:{) Jtiiiitinrd K.rfrii-iil('iiiir f,'( sfn f ion. -TUi- following ea>u
will illustrate clearly tlie diJlieulty s(mietimcs caused hy
this mischance.

v.. S.,iiiiianitMl woiiialiaKiil.'il. was nilmil Icil -)f on Dfccmlicr I, l!t|;i,
an. I It'll St. 'Iliomas's llospilal .laimaiy ■>. l!tl4. .sji,. l,,!.! si,nVir.l tiora
iiKliKi'.siioii tor niaiiy years, wiih pains cKinini: "ii alxMit liti.M'u niiniihs
allfi ; ikini; lo.xl. Slir liail ri.v.T hiMnv'liI n\> any l.lootl. |i was
liff^Nceii seven and ci^lil weeks pasl lie lasi [(eriod. .\l 7 am. nn the,
d,\y of adniissioii slie was seized wii!, violent pains in and aeioss the

al.domen. .liielly in ll i)ii:asl i iii!>i. These i)ains weie ol a shoot in>j

ehaiaetei and le.ielied litthl up to tiie shoulder re>;ion heliind. She was
Mck twice diniii); the day. and llio pains heeaine worse every hour.

The woman looked ill, Imt not distresseil ; the el ks were pale, l.ut

the lips not lilanrhed. Her pulse was small, Ki.S ; resi.ir.ii ions, :!(i ■
temperature. <tsj . She still eoiiiplained (.t pain in the al.domen. This
wasdislen.h'd. diil not move w.ll on r.-|iiral i..n. ami Iheic was ;;eneral
l.ut not veiy marke.l riyidily. She had ditVuse tendemess, espeeially
(.11 the left sideot the al.domen, where there appeared I o lie some jireater
distension. Tliere was v'reater resistanee to ).al|ialioii in the leH loin,
l.ut no tumour. (»ii (.ereussion there was dulness in l>..th Hanks. l,ni'
this was more marked on the lelt side, and extended into the splenic
region, and also across al.ove the pul.es. The lonyiie w as fiirieil ;
hri'ath otteilsjve ; l.owels not open. She compl.'iined ol ;;ieal thiistl
l.ut was not particularly restless. There was no vairinal discharge ; l.ut
the uterus was lar;.'er tli.in normal.

J»r. Wilson Stoker was present al the opeialioii. which took pl.ice
al.out niidniy:ht. .\n inci>i<.ii was made in the lower al.domen to the
left of the midline and the rectus muscle displaced to the I, ft. Th»;
].elvis and lower alidomen were full of Mood, and larce lots were
removed from the jiclvis. The lul.e-. on l.oth sides Wi'ie'iuickly lifted
and exaiuined. I.nl showed no evidence (.f disease or chaiiiie of an v kind.
The iitiMUs was s(.iiiewliat cnlaiKed. and just I.eyond I he at I aclimeni of
the left Fallopian tul.e was a depression which would admit the lip of a
foiclin^'er, from which .nlerial Mood was trickliiif; into the ].elvis ; this
was removed with the tiiln' ,ind ovary after lifraliiic of the all acliinenls
close to the ulerus. The blood continued lo come fnuii .ihose after the
pelvis liad lie.'ii emi>lied. and there was a laijre «|Uaiililv al.out 1 he
si.leeii which had not clotted and looked (juite fresh. With this lart;c
amount in the upper al.domen where, according,' to the p.itieiit. she had
first lelt pain.il was considered ad visaMe to make certain tlial there was

■J

I'KHroHATlON (H- TLC KRS. DKJKSTTVK T|{.\(T lti<

11

""7,""" '"' ""• '•' '"'!: '" '!"• M-.u.arh vrcum. A., in.o,,,,, «;,.

•lui.kly MiM.I.' in Ihr lui.lill.- hill' iilM.vr thr iiml.ili.ii.. ,,imI alil, Ii

""■"■ "•'' """■'' '•' ' itiiil 1.1 1 rlol, ^lill „l„„il t|„. >,,|,.,.||. iMMlimu

was t. ,11)1.1 II, a.lililioii i„ i|„. Mii.ill ..-Mi.inij j,, 1 1„. r,,||„,,i;,„ ,„|„. i„
■"•'•"I"" l-'i II. Kmint; iiij, ,.,,ij;aMiir .v.iiMiiiat i..n llir imU.- t,,i|,.,l aiiil
II \Vii>i,.,r.,ai.vlo ia|.i.lly.l.,M- l,..tli inrision, wit h nit.i i ii|,i,..Uiil iiirs

"I >ll..iii.'(i-li«ilt, rii,.,.. was DO tiiur levari, awavall I ),.• 1,1 1 which

ha.l a,r,i,i,„lal..,l. I,<,i «„„„. ^aliiir «a> l.ll in ihr pn ilonnin,. whirh was

.liaiiir.l Ihn.iiyh iH.lh woiiimIs. T|„. I | s..,.,im-.1 I„ havr |Miirlialr,l

.•v->.vwh..iv. Si,.,ih...,| sali.i.. ;v:,> ,,a.,.-.l ml.. ,h.' in.'.liaii l.a>iH.- v.im

.liiriiiUlh.'.>|„.iali..ii, aii.l. allh.,i>uh v.m y liMl.' 1,1 1 ..s.ap.M li.,i„ t h..

nil.ruml ml.,., aflcr ih,. al,.l..iii..|i w ,s „|„.i„.,l sji,. >..,.in..l i., ia|.i.llv

fail as l.l.,...l whi.h ha.l |.n.vi.,ii..ly i;.,i ,ni„ ih.^ p.i il.,i„.,iin wa- i.. v.mJ

II"- t...,l i,t III.. I...,l was ,ais..,l. ih.. Imil,. l,ai„laL;..l with llami..! an.l
waiiii wal.T l,.,nl..sap),li..l. Salili.. ,,. , ,,./»/» will, s,„„v l.iaii.ly wa,
Kiv.ii. •{ h.. pills,, yia.hially iii,pi.,v..l an, I .|i.. „ia.l.. «-....! pn.ai.-.-, y
va«iiial .li>..hai-v .-.piMai..! in a .lav .,i iw.. an.l n.,,,ii....l li'.alni..ni
Kit I I.Tain., away In. in lli.. .Iiaina>r.. I nl,..s. w|,j,.h w.t.. s.,.,n i,.ni.,v..l
'.111 Ih.. l.inp..,aliii.. was ji i..;:iilai ly iais...l f.,|- n.-aily I hi.... w....ks.

(4) .Iriifp Ai>pnifllrlli..\~T\n' iiMiid symptoms ,,f nn ,-,.'iil.'
itttiick ..f iipiH-M.licitis Jiavo alrciid^ l")|.,.i, iriv..ii snm.wliai
fnrly. so it is iiiiiiccs^aiy to refer fully to lliis pari of il,,.
subject a;,'aiM.

.\ history of previous attael<> Willi pain in tli.' iisiial situat i.xi,
and aecompaiiie.l l.y fever. \\.,ui.l iii.li..ate that tlier.' lia^ l„.,ii
a diseased ap|)eii.li.x, iMit the variety which i- most lik.-iy i,,
emulate the perforaliori (.f a fzastrie ulcer is that .,f a tiist
attack with ^aiijzrciie secondary to a concretion in an .i.lult, in
which there has heeii an unsuccessful attempt to locahs.. the
pus. Kven here the amount of fever would pr.,l,al,lv contra
in<licat<' pisfii,. p,.rforafion. The aj^e of the pati.nt' an.l th.'
position of greatest tenderness and ^rreatest .i. i;r.c of muscular
rigidity are helpful, yet it is po.sihh. that tlie appendix has
never .lescnded into the iliac fossa Imt is still sul, hepatic.

When it is a lirsf attack of appendicitis, tiiere is also a hist.trv
"f gastri, idcer. a distinct statement that the pain 1.(.gan i'n
fh<. epigastric region, and much free tliiiil, the diagnosi> i>
impossil)l(..

K. W.. a n,arii...l wnniaii, ai:...l .-i;!. wa. a. Imil I. .1 .,ii |',.|,i n.,, \ l'i, an,!
Nil li.r a ,(,nval.'s.fi,t li<,m.. mi .\pij|;i, liin.

• Ill r.l.iiiaiy IS r-h.. was sii.l.l.-nly ^.■l/.■,l will, >..v..i.. p.-.j,, ,„ ,|„.
••pi;;asnic i..<:i„n wli.-ii lyiiij: in l,...l in iln-.-ailv in„inin-. M,,. v. .mil,, I
;in.l il... v„initin^r was r..p,.at...l thiv.- times, whil...| ih.- pan, ili.l n..t'

170

THK AcrTE AimoMKN

Hill

! ■

'ill!

irifully iin|ii<.vf .iiiil wiis uIm. Im.I in 1 1„. mjlii |„w,.| ;il.,|.,in- ii. '||„.
liiivM-l» lia<l iii'tfit alli'i ail ciii'iiia

I'or tw.i vrar- s|i,. hail >uiT.mi il lioin pan. in 1 1,,- ii|i|i,m |.ail ol i In-

"'"' II. <>,iniiin nil aliniii hill an liMtir alli-r hhmU anil l.illow. .1 \>v si.k-

II.--S. wlii.li irlirvcilil. Th..!.' lia.lal>o (..■.■n lia'iii^r.-iii.M-. on ...ra.ioiis.

Wlifii liiHi sn-ii Mlir wa> ill a r<>n<lii>nn ..I .ollaior anil ic.|iiiir.l
sliiuillalii.li III irstoir Imt. SIh- I.M.k.il v.iv ill. ■j'iir al.ili.iii..|i ivaH

" "iil<'>- on ii'*|iiiali..ii, nmrli ili,l.n<l.-,l. I ui riwiil all ovii, iii><ic

••^I.iTiallyi.iillir lit'lii siilr. \mi|i inai kill t'l-iin al irnilniir-*. 'iJuTrwaH
ii.hMiliral.lf .liilni'ss m llir Hanks ami on I lir iij;|il si. I., ihis fvl.iiil.'.l
ii|i lo till' livti, 'i'lii' li-in|iiTaliiir was llli anil piilsr !M1 (small).

As tliiri- was th.. history of ^ ,s|ii,. „lriT, ami tlii> jiain I'oinnioiiiT.l in
»lii> Kasfrii- ri'L'ioii. wliilsj with K<'iH'ial liniilily ntiil liii.liTiii.s, tli.Ti' was
iiiiifli lliiiil. it, was ili'.i.li'd to I'viiloiT th.. slomarli tor |ii>s.sili|,. p.-if., ra-
tion. (In opfiiiinr till? piTitimi'iiin vrry llttir llniil was snn ; ihi>

ant.iior siirla I Ilir stoinarli was iioinial, hut as :, hanl i.atrh '.omIcI

hi' lilt oil till- posifiior snit'arc l.ilow thr Ifss.i . Mivatiiiv. tin- was
I'xniiiiiii'il hy liiinin); (lir stoma. Ii up. 'riimni;li an op.-ninu ImIow tin-
jiriNil.T niivatuio thr iM>iij;osti..l has., of an iilriT tin- sizf of ~i si\p,.|iiiy
hit was fxposnl. hut tlii'ii> was no pi'i f.iralion. It was ••ovrri'd in with
soini' l.iinhoit siitur.-s, hut tho i.ostnior sac was finpty. i:\]ilorati..ii
ill thi' nall-hlaiiiliT ri'v'ion tl-i\r f\it to a lai>;.' iiiiantitv ,,f wat.ry-
lookinjr I'lis with somi' llak.s of lymph, hut without oCnsiw ..il.niV.
Till' lianil pass.'il into tli«. aj.p.iiilis rrsiion <li<l not flnil anv in.iiiiatioii,
hut (hr pelvis was full of pus, wliirli pass.-,l int.. thr left' (lank. 'I In'
iiilisiincs wiTf not ilistrn.l.'.l ami the p.lvic imvmiis w.i.' normal.

.MthoiiKh thfif was no thi.k.iiiiiir in thi> ii-;iion of tl iri-iim. it was

jiossihle to f.'i'l s.uiiK invmilaiity of sinh , an. I i-xi. I. nation mail..

throiiKh a suprapul.i.' ilraina;;.. inrision (.\..'ml..l tor this puipo.sc)
showc.l a Kiii'KifiHiiis app.n.lix whirli hail jjivni way. This was ahoiit
:)i iiii'ht's lonjraii.l {raiiKr.nous in tin- ilistal two-thirds. \ li^atiir.^ «as
ajiplii'd, Init tho p.iitonnim was not siitiiifil ovi'r it. In" (Janln.r
ri-jiortiMl that tlir hmilliis iii/ticiiinieiis was thi, pviiiripal oij;anisni
l>r("s«.|it ill th.. i.iis irmovnl. (»p.iati..u ii-lirvnl her jiain ami slin
h.ok.'d iniirli hottrr n.'\t .lay. (In Maivli 10 a not.; w., ma.l.' to the
rll'iTt that tilt! ti'inp.iatiir.' had rontiniicd Iiinh (ahoin |02 in th,
I'Vi'iiiiiiT) with il puKsf of ahout Iimi to I2(>. .^u].]iur ition had o.tuii.mI
ill li.itli iiici.sjons, and an invcstiiiati.m of tlie pus sIiowimI th.- h,„,lh,,t
li;i<»iini,<iiii. A vari'iiii-wis mado ami jjiviMion F.^hiuaiy 2r> ami a-ain

on Maivh 2, with a slioht ftVi-ct on h..tli .i>i.,iis. i'»n .Manh stlic

lowiM- wound hcjran to .lisoliaiy.; moi.. fn-i'ly. 'Ilnro was I'vi.l.n. f

pl.'iiiitic I'lliision at th.' Ii'ft has.'.

A fortnight lati'i- then' was still son,.' f.'Vrr. alth..uj;li tli.' «,Mimls
liad I'los.'.l f.M- soiii.' tiini' ami notliinj; ahiiormal roiihl hi- found any-
whoro, I'xiM'pt at tho lift has,.. \o signs of iiiis.'hi.f i.iiiain.'.l at tlii-
I'lid of 'inothiT wi'rk.

(5) //^.s/rnV/.— All alliick of Insfrriii may .siimilalc |Mif..ni-
lion Miftic'icntly near to mi.sk'iul. At p. 23:5 is the account of

I

•'• :^i:<'

I'KIU'OHATION OF I'LCKHS, DMiKSTfVK T|{ \(T 171

th«> casr of a yonn- mirs,- wli., w,t> ..|H-nit.-.l ..n fur rpiuM-tiir

l.aiii hikI vi.mif iii^;. .ii|.| I 1,, he due to p.it'onition. In a lat<r

>iiiiul.ilioii wr foiiiid no rim.lity of miiMlis, n rn..,|,.ral.- |miI>...
rate, and ii sinilinu «'ii'c. ;.ltl.ou;.'li she ha.l " yrcat a-.-ny •
un.l voniiliiij;. |)r. |{...|,lai.l lia« tr...r,|. .1 M.ni.Avhat "^nulhiy
uttiu-ksiii.hloiotic wuiucn, ill t«oof wl,omo|„iatioii ha.l Imvii
prrforiind fwicc.

(•i) I'lrfnivliun uf Ih, ,j.,ll l,l„>l,lir ,l..„.|v Miiuilat.'s [...rf-ni.
fioii of ^'astiic aixl (liioilrnal iil.cr. Hm- fli.iv ^u\\ pi.-Lalily
).!• ii history of Kail-stori.. cohr, M.iiiciiiii.-, with jaiiii.li.r.
Th.- tni.hTiios woiiM )„. in the n l-ioii of il,,. irall hia.l.l. r.
and incision would he iv.|iii,vd ovn- that pait. F hav known'

mi acui. hihary ,oli,- ,hi.. f. "all ^toiK-s in a y. <^ .hloroii,-

female re>einl)lr perforation very e|o,ei\- at ils'oiiM'7.

(7) In 1,,,,1-rolir there w.Mild he ol'hrr >\iiiploiii, of lead
poisoiiin-r. and may !).■ a. history of piVMuii, attarks. I.iil the
lifst attack, as al.o the IJist of tli.' j;a^trie o/sv.. nf (ahe.
dorsalis, miuhi present some dilliciilty.

(X) Harer eoiiditions whieh re«|iiire nieniioii hiii med ii.>t ],,•
partieidarly di . us>e<l are aeiit<' dilatation of the Miniiach,
tliromlio^is of the mesenteric vcsmIs. irritant pni.oninj.'. ami
|>n<'iniioiiia Of Ihcs,. the only one \vlii<li re.imie, a special
notice is th.. last ; we have already referred to it in -peaking
<>t the re-, nd.lance of acute pulmonary inllaiiiinatinn |,. an
atta -k of acute appendicitis. An illustration of this ck,..e
re.semhlance may he <;iveii.

^ A. .<.. a>;.,l I'll, aihnillc.l ^ rel.niatv H and l.fi Man li |-> i'lrt
Ihc .lay 1m I,,,., lie was f,.,.|i„jr |,a.l wiih tr.ai.Tal pains al.oMl ll,.- I„„lv'
v..ii.ile,i aii.l e.Mil.l n..t I.i.miI,,. i.r..i» ily. II.' -avc a l,.M„rs .,l'a
lii..iit h > .1 \ siMps,;,. aii.l c.iaiilaine.i „t a.'iil.' pain in 1 1„. al.,l.,in.'ii vv In.li
ha.l .•.>i,un.iuM..i un la.iiis I,.!,,,.'. II.- ha.l l.,...n H.-at..! I,.r an atta.k

of a|.|...ml„itis t..„ y,.;,,- ImI.,,-... II,. k.-.l V..I V ill, hi- lips «..,,• whil,.

an. II.. app,.and alni.,>t .'„llaps,.,|. H.. ,.,„„,,l.,i„...l „f , i,.|„-i.|,.,i
.•tlxlonnnalpam; ha.l a puis.' KJo, aii.l t,in|Miat m.' le.'is ; n-,-piraii„ii-,

Th.' alMl.nn.'U uas ,|ui(,. ineti.ini, -s ,„, r.-piinti„ii. 'Ih,- o.ii ,,n
iM.tli si.l.'s w.T.' v.TV li-i,!. I In palpatieii fiiHl.Mii.-ss «a- pr..-,.|,i
o..nlin,,l t<. fh.- nVht si,].. ; ju th,. npp.T al„l„i„..,i il wa- v,.| v ,„„-
n,.iin<;,.l. whilst th.TO was son... shVht t..n,l..|ii.- n, tl,,- liju il,a,.' l.,-.a
.Nothinj; ..oiil.l |„. toll ni th.. ah<l..inf.|i m. ar...,uiii „l ii- .■Mi..ni.. ri.'i.lii v
ami t..|i.l.Tn..ss. Th.-i.. was no .lisi.n.sion uv al.i„,rnial ,l,ili„.- ~ Th"..
ivspiratory movc^inonts worn a!mof=t entirely tlu.naic and rather shallow

TTT

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MICROCOPY RESOLUTION TEST CHART

(ANSI and ISO TEST CHART No. 21

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^ /APPLIED IIVMGE Ir

'653 Eosf Mo." Sl-ee'

Rochester. Ne* Vcrk lAfc'J .sa

(7!fi) *82 - CJOO - Phone

(716) 288 - ^989 - fa»

> f

172

THE ACUTE ABDOMEN

S..nio pnin was romplaino.l of on tli.. right si.lo of tho alMlomon on ,lo,.p
mspiiatio... No al.nonnal sijr„s wnv pr..s,.iit aiivwli..,e over t\w ImiLM

All .■pij;astnc iiicisioi. was mad.^ and l.otli suifacos of tho stomacli
examined. Tli<' aiipendix was then icinov.d. it was kiiik.d l.ut
show...l no otlHT ..vidonoo of .'iseas,.. A larj;,. roun.l worn, oould ho
.■It 11. (lie smal lintcstmo. Th..|v was no fr..,- Huid in TX'lvis or in
flanks l,„t a small quantity was found botwc'ii the siomarl. and ant».ior
wall of th.. abdonion. On tho foljowinjr .lay h." still ha.l som.> pain in
th.. al.domon, l.ut ha.l passed a fair night. The pulse had in.prove.l.
At IL.tO It ha.l changed and was now 160. but iinprove.l after injection
of camplior and rectal saline. At S.'M) p.m. the pulse was 140 and
resj)irations 44. and h.' coughed up some rusty sputum. At 1 1 ;t.(p ni •
" tier., are now definite signs of iiiflammati.m at the lowr part of th.^
right lung posteriorly.'

On th.' 24tli he succ.«ed<>d in bursting open the woiin.ls as a result of
Jus violent coughing, aii.l it was necessary to resuturo.

l!..th lungs becani.- alfect.'d, but no further abdominal comphcatioii
ensued. 1 he tempcratiiro became normal on the twelfth day.

Pkhfouatiox.s of (Jastro-Jeji-xal Axn .Ikjixal L'u ers.
The kncnvlclgo that an ulceration of tho jojumiin i> one of
the causes of the acute alxhimei. which must he considered
by t}ie surgeon of the present day was due in tiie first place to
Brauns. In ].S!»<) he met with a cas(> in wJiich an ulcer of that
part of the small intestine perforated and jiroduced a fatal
peritonitis eleven months after a gastro-jejunostomv for pyloric
stenosis m a ma.i aged 25. In this instance the operation had
been by the posterior method, and the ulcer was found at the
necropsy. Since tliat time there have been recorded many
cases in which ulceration of the jejunum has re.pnred surgical
treatment, and in all of them the operati.jii of gastro-enteros-
tomy had been performed for the relief of some form of gastric
ulceration, or a result of it. From a clinical i)oint of vi<-w
they may be divided into two clas.ses— the chronic and the
acute perforative. In the former we are most lik.>ly to .n>t
an idcer which will produce local symptoms before pc^iforatLn
;nto the peritoneum, if it does perforate ; in the latter no
warning is given, but if the patient has previously had a
perforation of a stomach ulcer he thinks that a similar'accident
has occurred again. I have purposely refrained from using
tho term '• peptic " as applied to these ulcers, for it is not
proved that they are all of them due to hyperacidity of tho
gastric juice ; indeed, in more than one tho state of the gastric

PEKFORATIOX OF rLCHHS, DIUESTIVH TRACT I7;{

juico has boon (li-fiiiitcly desciilH'd as normal. TIk- apiH-araiicc
in tlireu out of tlu! four pcrf orations of this kind tl.at liavc
been uikUt my personal notiw was similar to that (.f sonic
iUMitc perforated gastric or duodenal ulcers. Tl,c\- also
resembled the ulcer in two eases of perforation of ihi* ileum
during the course (,f typln.id fever.i to which I shall refer
later (sec p. 1«J) ; the naked-eye appearances weiv (piite
similar. (Some of these ulcers arc probably due to an acute
bacterial inva.sion. but [ do not think tlic term -peptic '
should be used. It is an interesting fact, however, that thcv
arc only met with after the operation of gastrojejunostomy,
and ehielly after the anterior operation— for example, out of
some 77 cases 52 followed anterior gastnj-jejuiiostomy.- fn
the paper here referred to a collection of l(M) cases has been
made.

The most .startling complication of jejunal ulcer is acute
perforation when the patient is apparently (luite well in licaitli.
and in this, as in other eomplications. it resembles simple
ulcers of the other parts of the digestive tract. This accident
happened in 21 patients, but inasmuch as in two of them it
occurred twice at consiilerable intervals. 2:5 instances arc now
known. Oj)cration performed at the earliest oppoilunity
was succes.sful in saving life on nine occasions {(Joepel 2 '•
Hybrinctte. 1 ' ; Maylard, 2 ' ; liattle. 4). This improved'
record of re.sult.s for operation 'iiakcs it appear tiiat operation
for that accident has rendered it less dangerous than the slow
extension of an ulcer which is shut off from the i)eiitoiicum
by means of adhesions. The formation of a localised absces.s
is known to follow at times, and may lead to an intestinal
fistula, but it may be necessary to operate f(;r the local ulcera-
tion, on account of the troublesome symptoms which it causes.
This has involved resection of the ulcerated bowel, the jejunal
end being placed into the stomach and the duodenal end into
the side of the jejunum lower down.

The cases which have been under my tn-atment are as
folhnvs : —

' liiiicet. I'.iii:!, Vol. II., p. 8t;:t.

^ I'riirersal JU<i:,ul Jlt;;i,d, MoyjiilKiii, Jaiiiiaiv. I'.'ll'.
" ■• Koii'.Ti'ss bcriclit," l:iii:;. p. id.
' Ili'iiir (!,• C/iintri/ir, rjutj, |,. ;io.
^ Luncct, rjlu, Vul. I.

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171

THK ACITK AP.DOMKX

< M .„l,M,ss„.„ ,1,,. .l,,!,,,;,..,, uus ,„.,<l..n.„.|y ,liM.-,Ml,.,l aiMl .li.l „.,t

I.U. tM.„,^s,,„..,.,l im.n..,lM„..l.valM,v...h..„„.l.ili,-„.. ' |,is„.uM,.u
ys M„.M m,Mk.-,l ,„ ,1,.. ..,,i.as,,.i.- a.ul iMnlMli.-.l ....i,,,,, ,„, ,|,.,,. „,'

. .11 ...Ml, I,.. |,.lt. u..r was ,|„. .l,.l,i..ss a shilliuj;- „n,: Kls-ul,,.,-.. th,.
HO.,, was ot a lynu.au,,,.. ..hara..,..,r, ,l,is I,n„. ..s,M.,.iallv .uark. 1 u •
••JH^as,,,,. n.„.„, Tl... liv.., .l„lu..ss was o.,lif..,,^..,,. ,1... u. . • • "

liLus^O ""^ '• '■■■"l--""". !'^< : puis... I.M.; ,..s,,i,,.

■' , '' •''"'" V;'^""'^ '■'"<"'• ">ul tl>.. t.,ll„wi>.u Inst.Mv was ol.taiu.Ml

M...... ol wlurl. was s„l,s..„u..,U ly vnilini. II,. i.aU su.lV, ■, , i

.H.l.,..s„.,n all..,- I... l,....a,n.. 10 yoars ..1,1. au,l ,1.,,.,. L^mL Z

;"■""""'• '""I "" ">';• <•.■ two o,H-asi,.ns ]„. l„„„,ht „,. ,„1. Tw.-u, V

"" .....uthsiMvvn.usly 1... ha.l ...ul..rK,„K. an „,M.rati ,u in J{i,„.ia..l , .

ms' ir:;; : ''•'■';''^%'^"""" >-"« '-<i »,. a,,„.oxi,ua,.. ,1.0

t.l Man h 4. 1 )..4 wli.;n h,. was s,.,„.,l with paiu in th,. al..l,„n .|i. a.ul

..i^l to .,. M.to th,. hosp.tal a.ain for " ,.l,s„.,u-tio,. " ; at this o,.orU n

th('Mmi)hy-s l.iitton wasi,.„„,v,.a. oi.ii.ui,ui

A. th.. .,i„.,atio.u which was ,„Ml„nn..,l al.o,., fiv hours alt.T th..

rZZit^u'' ^"<:;;>-,i'"-- -" .-'...atio,,. a isi,,,. „':':, !;

IV \. ""<i'lli' ..i- alH.v.. ,h,. u,nl,ili,.us through th.. r.....,.s

w ". "'!'"■'' """ ''"^I''^'"''^ ...Uwanls. Tlu.r.. was a r.ish of Js

pi. M lit. .1 liiis „a> ,.mu-t..n",l to ,li,ninish its siz.^ a.ul .rain m,m> room
""'1 -..l>t..Hi of nuu.h .as. The oi„.,u„. ,vas ..los..,l wiU L,- .r^ k
Maur,.san,ltho,.o,lr..,ur,u.,l. Th. st.>n.ach. whi,.h was ,^.h S', ,u! ^
. .l.awu ,„,o ,h,. wo,.,ul; tho poiut of atta,.hmo,a of th- al

'I .. about i uch .u .l.anu.t.T, l„..at..,l ia tlu. a.u.Mior part of ,h^

;^ ". ^Ir .: f ;• '"•.^•r"';'^'' -"^ "'<■ "i>p-- r-t of ti^o .j,..i„„„„,

.,, ' ; ' e'"l't.«'<l of Has thn.UKli th,. ul,.,.r, and tij.s was

I .1 ....ne. ,,. w>th a siu,!,. row of L,.„,l...rt .sutu.vs. The. , K

. . li i'. u'"" • '"' :'*•" '':•" '•"' ^•"'""'■- -^ -"'" —.ut ,.f free

.u.u.at (luKl uas juv^eut .u the alMlo.niual cavity, wi.h patches of

lyn.ph oa the uUe.ti.ua coil. A second luci.iou'wa. „.Se in the

:^?^-

I 'K HI- ORATION OF rL( KliS. DKaXIIVK TI!.\(T 17,-.

m..iah. iHu. al,..v.. ,1... ,,„|,..s ami ,1... p..,„ou,al ...ui.v .l,„n.„,hlv

«o„ml ..I..M..1. I h,. ,„auV .,,,,,,,,1 ,,.,„,i,i,m :,. tliv ...ul „1 1 !„■ „,„.,,. ,„u

'''".■'■'' '- '"" ""I'll '" '-■'"111 in 111.- MlliT pn,...,'- „r ,|i.- ,-,<,■ II,.

«as M,.k ,|„.... ,,„„.> ,lun„. ,1,.. mj,t l„i;„niuu Hm- .,.,ti.,n. lMm..i„..

1' ••ii'-li ninr !:„;;,• ,|,>au. ,t !.•. ,.1 :;r....M.>h llui.l. lu ,|„. ,n,„nn'' ■>
• ii|"'"lii"- '■».■„,,, wa. M,l,niuis„.,r,l wi,h a v.tv ..mhI n.>,ill„ S„I,,|,"m..
«• ma.u..>nnM (lu., l-a>p,Mml„|s) was .iv,.„ .v., v l„ur i,.,ms. Th..
"l"l'-i'-a was ^..,^,|i,l„lv .I,.,,.,.,!,..! a,ul ,.,„ v,, v l-iul.-r. U ,„..vr.l „.
ti!"ls '-.(I""' "' "■^'"'"'""- """•-'' '"" l"'ly- I'lilx'. I'M; n-pira-
■llM. lH,w..|s a.t..,l „u Uu- l.,ll„uiu;r .lay, .1,,. al„l..„Mual ,lis,..UM„u

s n all,, „,. ,|...n. l„.„... v,.,.v |„,1,. ,lis..ha,.... T« ,vs lal..,- tirs „as

;st;:;r:r'- '"■"•'-"•• ''■■^i'^^^"-A'i.i--^.iKiv..i. ......

Tlic second cas,. was a very intcivstin<_r .,ii.-. Im-Iii,. aliiK.sl
I'MHnu. tnmi llu. ,.„„rs,. „f tl... va.inus .n.Hliti.Mis }„,• xvl,i,.|,

npciMtidll M.ls lC((iij|c(|.

An a.i.nani.Ml w,„„an. a;;v,l 37, was a-liuitt.,! ^ „u Ma.rh LV,. I'.o;! >

^!^^uTr^ "1 P".l...at...l .as„.i,. ul,.-r, « hiH> l.a.l , nn..,.,-.! lour

...Hi a halt hours |„.|on.. Opcratu.u was ,.,,.|o.-.u..,l at I M,", p ,„ a.ul
au ulo...- ,u.a,- th. pylorus an.l on th,- aufrior surtan. was l',,,,,! an.l
M.tu,...l, th.. jM.ntou..al .•avny w „.,. „„, au.i the p..|vis .Iraiu..!. M
th,. opvratiou ,t was not,.d that • ..r..was ahvu-lya .oo.l a..al of narrow -
. Nj. th.. pylorus. ,h.. l.-lt hospital on May 12 and co„tinu..,l w..ll

... Apnl, 1.M4, aa.l aut..nor-astro-i,,jun,.sto,nv iKrlonn,.,!. Th..
st.„ua,.hwas,l,lal,.,l.tia.h,w,rl,ord,rn.a..hin;;,hH..v,.|ol,h,.uu,h,!i,-us

A '7',V ;'■"■■' ')",- ""':''' •:;'"^"''''^'^'- 'J'""' "l"ratio„ wa^ o„ ,h.. ,Mh. an.l
hht' li.ft hospital on Aim) 2,S.

.>^h.. r..j.a.-.l..d l,,rs,.lf as crnvi] ,,ntil May .>, V,,<.:,. wh.u sh.. was a.-ain
M.ut to tlR. hosjutal l.y Dr. .1. SroU liatla.ns ^

Ahout six- hours iH.lor,. a.l,„is>io,. .s].,. ha.l a s..v..n. atta.-k of pain
,.sl.i...ally ou tho si.l, ol th.. abdoni..,!, with vonut,,,,. Th,. l,ow..|s

Jiatl a,.t,.,l twici' . (lav.

l.i th,. ward tl,r ab.loim.R .lid not ai.j.,.ar dist,.M,l,.,l an.l n.ov.d h,','\v
m r,.spnati.,n, J h,. n.sonan,.e was normal in all parts. I'uUr :> ■
U....lK.rature nonnal. Th.r,. was sli.h, ,..H.|..r„,.ss all ov.r th,. al,.l,m,.;;
moi,. ..vnh.nt ahov,. an.l to the l,.|t oi th,,. nml,ilicus

.-.,. v,.nnud Uvo .,r thr..,. tim,.> ,lurin.u- th,. niiiht. On th,- n.orninLr

0 the Oth th.. t,.n.p,.ratnr,. had n up to !.!. .^ and a .listen,],-! ..oil

01 small mt,.stin.. was s..,.n ahov,. un,l to th,. leit ol th.. un.biheus. Th.re

' ii-aiisaclioii.s 11. Soc. .Med., .hiiie. l',H<:i,

-'ii'-]fl^^'

i!:

1 : ■

i;'

I7«}

I'lIK Aciri-: AMDOMKN

rnon: inaikcd over tin- <listi'nilfil

was tfiidcnii'.- . us licfore, l»ut it
coil.

Wli.ii s.'.n by „„• at 2 p.m. Ilio .•uiidiliou was iiiiicli as al.ow ilr-
scnb.d. but thr flistrusioiK.f th.' small iiil.siiu.. in the uiiihiii.al icuioa
was mratrr. ami tlicic was visible piii^filsis.

0|. •■ration was i.nroiiii.d t wnitv-ilifvc hours alter tlio first ousel (,f
I>airi. Ihe alxlomeu beiu;; oj.eued tliroui^li the left re<'tus sheath about,
ail ineh Iroui the middle liue. A red au.l distended coil of small intesliu.^
ju-csented -vhiJi. traced upwanls, led (o tli.' old irastro-outerostomv
juiu;tion ; from this a greatly distended .v.il passed downwards, on tlu-
anterior aspect of whieh. IJ inch from the line of junetiou. was a rounded
opening from wliieli pis and intestinal contents were esca,.in^'. The
ooiis n.'ar were intlamed. o-dematous and disi..uded. there beimj lymph
on the surfaces near the perforation. .V knife was intioduce.l throuj;h
the ulcr and a cut made ui)wards, so fliat the liu<- of junction betwi-en
the stomach and intestine eoidd be exidoreil ; the liu'i:er passed easily
into the stomacli and then into the jejunum beyi.nd the line of juuetioi'i
'J here Jiad been no contraction of the opeiiiuj;. After the distended
coils had been emptied, the incision was closed with Lembert silk sutures
and the intestine washed with sterilised saline. A .second incision was
now made in the middle line above the i>ubes throuuv the old .scar and
the i)elvis eini>tied of a small amomit of purulent fluid, which was not of
olTensive odour. It was cleans..d uith stciili.sc.l .siline.aiid both wounds
sutured, without drainage. Shock was count.-racted by the administra-
tion of half a i)int of saline iter irrtum every two hoiirs. The patient
recovered and left a month later.

.She came at;aiu for operatioui in I!iii(! on account of symi>toins which
she, lier.self diagnosed as due to ■■ perforation." .she" had not been
feelinj,' very well foi a fortnight, but there liad been ncthiujr very delinite.
There was. however, some pain in the abdomen <m March 12 which she
could not localise. At i> a.m. on the 14th she had felt a sudd.'ii increase
m pain, which was now in t... upper part of the abdomen, and site
vomited.

At 3 p.m. she was lying on lier back, with eyes sligl tlj sunken, but
not at all anxiou.s-lookiiig. Her pul.sc was 8.j and temperature h»t-6\
The abdomen was nioviiij; fairly on respiration. On examination it wa.s
tender, especially to the left of the umbilicus, and still more so near the
lower end of the sea- representinj; the site of tlie previous operation for
perforated jejunal ulcer. In that region the mii.scular rigidit v was most
marked, and there wiis distinct swelling. There was impaiicd resonance
towards the left flank. No visible peristalsis ; the Uvcr duluess was
not changed.

Incision was made through the h.ft rectus slieath and the muscle
displaced inwards. A thin purulent fluid was present on opening the
Iteritoneiun ; and a coil of disl,.nded small intestine of a dull red colour,
liaving some iiatches of lymi>h on its sii-tace, iireseiited immediately
under the oiiening. Tw • three patch- s of yellow lymph were espe-
cially evident on the line ol junction of the stomach and small intestine ;

' Clin. Soe. Trang., Vol. XL., p, iM.

PKHFOHATIOX OK rUKHs. „K;KsTrv|.: TMA( T ,;:

;;•;;; ';f>i.-;m.„i,„„„.w,i,.,,., ,,.,„,,,,,,,„

'liiiclly liniiii;.'li il I

""'""''i"i''^"'^<"'i<-.VM„M,.,noMll,,|,,,.MlH

'"'''■""'"• •"III "Inn >|„- u.i>>|„,u„
"' "^1^ II" V"-lili,il liriiii.i.

"!'■ "H.minjr of \,„.„., •..;■'; "'''"' "'M-'.v-l ^ I l.-.lth uui,l

l'avin,Hn,l.;.,k,,.J"Lh;i ', '''/'''.'''r "'""" ''^'"l-' '^^ "'-n

I'ar. ..1 his al. I , >; m i T "■''"•'.""'' ■' ^'"''l"" I'^'in i-i -I,- ,.,.,.,.,
n..t. I.OW..4. V ., i"'!'"' "■1:"" "";' '""' "•" -'I- ",. l!:„|

;::;c-;:!t;i;r;:;:i-,.:; r r

''I" I'V I ! ••!(. Il,n... I . • "'"'■■'' ""'^' "' ""■ I'''"i "

nil.
Ill

I-;.
III!
I'l -

"t tlic left i(.,.|,is

I sid.. ,.| ||„. Ml..i,,iiifii :iniC\h,' limMiiv

"I iiic icn !(•<■ us, It \v:i^ (•iiTi>i.l..i,.,l II, ., ri -i Mumny

-lini.sin. i,s,.|f al ... 1 i r' ^^^— •^'I'i.i^aM.i ^n„l„.liv

.viioti.v,,-,ii.lt,„,n,l.rlM<i tiMi l„. I,;„iini.l,

*^'i.- ti- .wo ....nuioiis ......nioi;;:;i ,:.,•;",;•'';!' '''■''''■

;:*;r;';.;™";s f-;;,:;; ;,|;r s;- -^ •- 1-™ "- «■- i™"!: " ; I;::

1, : . " '" ""•■si 1110 ^Ml]i )]i,, ailt.Tlor wall „r il„. „, I.

I'fiii!: on tl:,- ii.le.stiiial poitM.n ..I l|

ic aiit.Tior wail ol 1 h,. Moinarli,

"";;'""■" ""I""" "„.„.„, it !:;;';;:;s:,:;:;:';t,:,.Ji

A. A.

ITS

THK .\cni-; ARDv MKX

ll I III' WiiUllll llli^lll

I III' aiiiiiiinl

••l<'aii>i.|. M.1,1.' Iliinl |>|,..<1 Inirii tlir |m'1\i,, an

wilhoiu .|,aiiia«.'. Tl,.. i.aliriit mail.' a u 1 irniMiv • „„„.„„,

"' ' ""' '" ""- '•■'*'■ "■'- ' 'I'^"."'iv..|.v Miiall anil i.t a Kiv.'m>l. .•..loin

williiMil i.iloi.r. l,ni navi' .Irliiui.' .'vi.!..,,,'.' ..I its p, ■.■>.. ,.l .•M.'M.ioii

.l"«iiwaiiU. lit.lly l.y III.' iii.n'aM' in lli.'.lnll ai.'a rmli.'.'.l l,v l>r Cmn,.
ami >.'.'„n.liy l.y .!,.' >,„.'a.l ..I th.. li.n,li'ni.'s>. Tl,.' .,|M.,ali..n vva-i
l"''t"ni'i'il so >ooM alli'i- iM'iloiatioii il.al no lvin|>li lia.l loin.i'.l ami 1
'■onMili'Mlial ll,.' I'a-.' irll.Tl, v.'i.v -i.'al .'iv.lil on l»r. rmii...

Tli.'ic arc various |)oi„t> in tlioc ca-i's wliicj, arc \v..rtli
rccapituiatin.,' :

(I) 'I'lu- ulcers gave in. irilitiiati.m .,f tlicir jircscricc until
jK-rforation occurred.

(-') The symptoms were very niucli like those n'>uitin<r fi .m
iui ol.struction by a ),aiiil. there heinj,' localise,! distension
and, ni one iiistaiwe. peristalsis of the bowel near the i)erfora-
tion.

{."5) The distension of the bowel when exposed was found to
be eonsiderabi,-. lu,t it was relieved by forcinji the contain.',!
giis through th.' perforation, after which, maniiuilation was
I'iisy. It was not easy to find th,- perforation in all.
(4) III lu) case was it necessary to e.xci.se the ulcer,
(a) In two instances a counter ■oi)eniiig was reipiired f.)r the
.satisfactory cleansing ,.f the ju-lvis. but Ix.tli w,.unds were
cl.)sed without drainage in the second case.
_ Tlu> proi),)rtioii of rcconled cases of simple uh'cr of the
jejunum to the cases of gastro-eiiterosfomv appears vi-rv
much against the anterior meth,),l of „perati,)n ; but tin's
tells as an argument less f,.rcil)ly than woul.l appear, because
It IS very pro!)a])le that the anterior operation has been p,.r-
fonned more frcjuently than the posterior. I fornu'rlv
c.msnlered that the ant,>rior operation possessed advantages
which were likely to make it the more favoure,! operation'of
the tw., n, a general way. an.l that the danger of the formation
ot this kin.l of ulcer was so slight that it might be negl(>cted iii
eons., eriiig the question. The introduction of the posterior
no loop " operation by the ^Fayos has. however, given us
even better results, which in my opinion constitute it the ),est
of the numerous methods before the i>rofession. Since the
account of it was ,.ublished. I have invariably i.crforme.' the
posterior operation in ca.ses requiring -.'astro-jejunostom .-, if
the state of the parts involved permitt. .1.

i'KHF(mATioxoFr..Kns. „n;,,sT,v;:T,.,,r ,:,.

J'KHlnKAnoNs UK T..,.; Smu,. Int,;s,,m. ,,,,, ,„,„

" -^^ •^"\' 1^ "I Tm-||.)1|, |.-|;\,.;,.

Altliniiuh fl„. fatal (•har,i.|,.r ,,f , ,, .f

-- fully n...o«ni...,,.„,,.,,;;;/;;';-;Vyi;'-i'^^

y.w that IVnf,..s,.r b.v,|,.n M„n. , "''^ ""'>■ ''"'"'u 'I,,,

litst fin,.-. • ' '"*'''^'"' •^'"•>'l'</ ..,..., at,.,! tur, Ik-

"'"''i- ,m'..u|. .Iim.,s fn.,„ „„„, „,• ,,„, , .

•''''•i''«Hu..our..ofaMilln...u-,.: ',;''''•" '''■^"'"1-

(•alcuii,tc( l.v l^r M, .,.(,,.• \l r .'"'I''""'"- It lia- Ii.tm
II ■ M((r()i .Miickcii/.ic till •' •' .

"11 ••"scs of ty|,l.,.i,| U'vvr "' '"■'' "'•'''■ "»

(Hiiizard j,riv..s :i-7;! p,.,

f<'iit.) <li(. f,„,„ ,||j^ ,.,„„

I>li<ati..ii : and. furtluT.
thai (lite, per cciil.df Hicni
<><'<'iir (luniiK tiir second,
tliinl. or fourth weeks of
tlir ilhiess. His lecture in
tlif /Miiccf of Septenihcr
-'<i. I !•<•:{. is both interest -
"ig and instructive and
"ill well repay perusal

:; .p, "" ' ' ''■'■'•■' :nv >ii.,wii I!

Dr. E. \V. (Joodall found perforation i.. •>- ..

fatal cases at tlu-Mo„H.rtonllv,.ri,-':V7 ;■'■'''■ ''^
•'""''>-''f«--sonlytworecoverdor ,;'''''■ '"'^
-tl'- after .louh.fui ,H.rforation.e ..;''' '''^''"'^
""•-"•'"'"toryform'of ,vph,d or ;:, '"•':''•''''' ''^
Mtill.-noughtogotohed.hu,i :,. : V'''T'' '""

-:;:^rty,;;a:;;;:;-;:; :!-::-

tf.oso suggested for tJ.e nurs,- l.v (,.,.,, i, ^ ' /tf I'"'"; I"

^'"forced its ooeurn.nee may he' overIo„l " / v . '""r, "

I-t,ents are under skilled Observation ' , er.te h;: ''"^'^
c laneo f,.f ♦! I ■ I • iMiKrou there i> :.

•'-- fo.- thetn which is not am;;d;:d\n;::;:ni/''''" ^

other "r.iiir. -F'! >'i.ui\ or ihr.se in our

.luup... Ihey are watel.ed from ,he begitn.ing. and

N 2

- 1 r-

liii-.

I

'If"*

i

I MO

TirK Ad'TK Ann<>Mi:x

|in'|iaratioii r-luiiild he niadr fur (i|)<riiliiiii jit ilir r.nlic-t
iiiiimcnf it' lliric i^ any .-fri(iii> clmii;:!' in tlic alMlimiinal
>yin|)ltiin>.

W'liiUt ill ain])uIii(oiy raM'> and ca-c* of a iiiilil nature the
>ymptiniis me dt'linitc. tlu y may )>c ill niarl.cd in a man who
is ill a (•(iiidiiion a|i|)i<(acliin^ tlir l\|iliMiii -iat".

'riicn nu.iiii the contcnl- 1 the ilriini in tlii- di-ra~<' an'
fi'iM, iitly >caiity. and the |i(it'orat ion may not alloM of tlif
imnu'diali' I'Mapf of miicli llui( at all event-, the >eii>itivc
|)critniiciim i> not ll()odc<l at once with a lii^'lily initatinji arid
conipouiid, tlic amount of wliieli ra|)idl\ increax-- liom minute
to minute, us in ju'if oral ion of tlie sloiiacli.

Tlie account of two cases on wi icli I operated at tlic irijiievf
of my colleague. ])r. Hector .MacUeii/ie, v.ill show to some
extent tlic conditions -wliich may lii' met with -when the general
state of the patients is favouralije.

In tlie lirst. perforation cccuired on the teiitli day of the
first relapse, and .symptoms of peiforalion had l»een noted
twelve hours liefor" the opt'ratioii. which look place on
December 4, 1!M)I. when he was under treatmeiu for tlu
ft'vor. The liistory was as follows :- —

TIm' fever had Inslrtl almiil tliirl y da.vs ; llinc wii-- linn a immimI nf
lioniial Iciiipcraliirc laslinj; cinlil (lavs, lollnwcd l>y a ii'!a)(>c. and mi
the tciilli day (if tills lie ('(iiniilaiiicd ol a sudden and severe |iaiii in I he
iiliddineii which wiike him '■)•. ,\lier an aclion (il his Ixiwejs he went
to sleep ajiain and >lept for nearly two honis. hei, u' aKain awakened hy
the pain. Me did not vomit tint il >even lioiiis allei I he eornnieneeineiil
(if syinjitoms.

He was a man ajred J2. M the lime of oiieiaiioii he had pain,
distension, shift iiiy dnlness in the Hanks, evlreme lendeiness in the
rijiht iliac fossa, and a complele aliseiiee of diiliie>s in the liver re;;ioii.
The pulse was '.».") ; respirations, 2ti ; temperalnre. JuJ-l . The
teiniierature fell raiiidly to ilT after operation, hut soon rose .iirain.

At In.Un a.m. incision in the median line helow the iiml>ilirM> showed
a collection of thin yell(iwi>ii fluid under the peritoneum, wilh some
lymph on this .•Niirfaee of the small intestine. Comiiii: liom iln' upjier
aiifilc of the wound was j thin louirue of oineiilnm adheicul at iis
extremity to a coil of the sma'l ImiwcI, which aiipeared paler and more
contracted than the other coii ni'ound. On pullini: on this ]iieee of
omentum the portion of intestine to wliich it adhered rota'cd and
showed a perforation from which the same kind of fluid was comiiitr.
This perforation was rounded and sharjily cu . ineasuiinji alxint i ineh
acro.-is. \ silk suture was ])lace(l across this o]ieninu to draw the
edge.-* together, aiul the ulcer invagiuatcd with Lembert silk sutures

..M

I'F-l'FoMVTinN oK I'M K|{s, DKJKSTIVF- T|{.\( T IM

'-'';■ ^;',"";- ','"■ '"";■' ^''-'••""" «• "-1...1 ..,„ „„i. .,..,,im..i
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A l.:Mh a,...l -s „,„ ...IMHII..,! „„ .1, , 7. I,,,,.,. ,„. ,,„„„
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: ■ '7"":" ^""'- I- -low,,,., nn ,1,.. :.,, „,,.,. ,„„„ ,., \

"'"' "'::'""i ■; '^ '— • ^""i ^n.ini.v ,Mnk „ ....... Th. all ' ;

«.»..ii....v..,....a,,,M,,..v,..i .,.,,. T,,..,... ,„,., .i,M..n.:; :

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' ^"" ". Ihr .■,„ua>li.r iryion nn ,ouj:lnii^. wl,-,.. ll,,.,.. i. ,„.,..• Uu,U-v'
..-^ .... ,.,...>,.,... To.,,,,.. ..!..a„..r. \U,su-U ^^..|| .,,,...,.,1 ,„,,. .,„.„,'

I . ,M,.^ I,..,., was a s„.l.l..., .MM., ,„ l,.„H„al ,a,... ,..„.,„..l ,,n„i.,.

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""'I. "...><■. Mis ..xpicssM, . was ai,x,..„s. ami ..ys siiuli,.,, n.' l-.v
«,.l. (he k....... .l,aw.,,i,,.a.,.l..„„i,,lai.,...l m,„..|, .,n|,.. al..l.„„in.,| ..ain

«.'.. li «as „,., S..V..,.. al...,i, ,1... „ml.il„...... an.l wa. a..,avu,..d J

"" . •s,ma i„n, was „.!.l i„i.lly. Ti... iv^iMai,.... a.,.l ,...„l..n,..ss wn..

.., >.,nk..,l, ,.s....-,all,v ,„ .1... li.i,, ,|ia.. i...ui..„. Ti,,.,-.. was i... .l,.|„....

. U... ..a.,ks a„.l ,1„. liv,.,. ,l,.l,„.ss was u„t ..„..,„a..|,..,l ..„. TI,,. ,m,K.,

7^ "- "'-»• a...l small.., ,l,a.. I...I..1,.. l.ii, ,!„. ,,„.,,..,,,„„... wa' ,1 .
j l""i.Ml (.,M.,ati...i was ,.,.r(.Mm,..l a. T.lr, ,..„... l-y. a...l , l„......,,.a,,..r

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"II. <• small

ma.l... au.l s.,ni.. thin, li.),, y..||.,w ,.. -Hk.. (i,i„l ...Mtaii.i,,, ..,„.,. s,„a,i
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.•'..Is ,.1 m.,.stme. (.1, ,,a..inj: a .■.„! ,l„w„v u.ls t..wa,.ls ,l,o ,'.,-1
av.- th,.,-.. was s.„„. t..,.n.l a nmml, ..|..a„ .l...,! ,„M-f.„a,i„i. al...,.r

. ....•!. .., .l,an,..l..,.. w.th a sI.m.uI. a.li;,.,oiu ... it .,,1 i,s i,„i,.r si,l,. Tl i,-

..l.Hung was .-losod with ].,.m„o,t siitiirc-s. Affr the lo./.r alMl.Mue,

\Hi

11 IK A( ri'K \mM»Mi;\

IkiiI Imi I W.l'lnil Hill till' ,|lillii|||i'll Wjl-.flll-.lll VMllllllll lIlilllKI).'!'. 'I lie

|i;iiii'iii '-. 11 Hill 1 1 Hill jii ihr I'liil III till- ii|ii>riiliiiii ua.> u I. Un iIh- | |i|i

llir \\ iihil icai'lioh. whii-li liiiil lirrli ihumI ivc tii-lori- I In- oiirrnl mii, \\hh
now |ni-.iiJM', 'llic aliiloiiiiiial w...iinl iliil iiiit I'liisi- Naii'larliii ilv liir
Miliif I IIIH-, ami III- iiiily Icll nri Sr|iiriiilpi-i In. , nj. min wa-. rrailiiiiitril
on Si-|iii-iiiliii IH III till- >iiiiii' vcar Im |nTJ"xiili» iil iIk linnii. ||i< win
i.ailimllril on .laniiaiv ;i. I'.tii:i. loi alxloininal |iain, uliirli hail nmir
on allti a »li|i wliin lir wa^ timvinii .1 «jii-k ot coiils. 'I'liis w.i-; vriv
"i-M'if. anil \va> inolialily tin- ii-»iill of rii|iliiii' o| f,oiiii' uilln 'loin.
Nr\l .Mill lie raiiif iiiiilii oli^i rvat Ion avMiri liir alisrc*.* of the linnii.
ulinli i-loM'il iiniln I iraliniiil . Tin- |iiis ronlainnl l,v|ilioiil liarilll. anil
I lir Ihiiii- was lialril l>il( liol lirriioi-il.

F may iiicnlioii Jitrc. hs ii cuiiuiis aildition to iIiIn lii>t<iiv,
♦ liiif Hic Ihi^'h WdiiiHJ nn|)i-iic(l iittir lie left flic lidspitjii, and
as ifcciitly as DtcciiilK r. 1!M»». tlic |»us loiitaiiu-il fyplioiil
bacilli oil l)actcrioloj;icHl cxaininatioii. If is sad to relate fiiaf
his wife, wild (|re->ed jiis •\vomid for liiiii. eaiijilit typhoid aliotit
Aiigii.--f. 1!MU, and died soon after admission to flic ho>pital as
a reMdt of the severity of the attaeU.

JtiJIiKHct of l'irf.,iiili»ii of Tiiiihoid VIcnon thr Tini/itrulHrf.

The eliarf (Fi^'. JS) illii>trafes the rapid fall to !Mi H . rehound
to inj h on eveniiif^ 01 operation; then a jjradiial rt-turn
to the previous run of temperatures until, on the seventii (hvy
after tlie perforation, the records were mueli the same as
(ufore it. This patient luul a second relapse in January and
a third in Kehruarv of tlic following year. l)ul recovered.

In hotli instances the ulcers were single and of a ; •••iched-
out eiiaracter. with surrounding healthy tissue, am. did not
suggest that they result<'d from the spread ,)f the necrotic
process seen in the Peycr's patch of an ordinary typhoid
j)atiiiit

There may ))c more than one j»erf oration, but as a rule
(ill »H )ier cent.) it is solitary and small. The incision should
therefore be made near the middle line, rather than over the
iliac fo>>a.

Messieurs Dujarier and Matthiiw' state that it is found in
the last 00 centimetres of the lower end of the ileum in !t:{-5l
per cent., ai;l it is almost always on the free border of the gut.

Another perforation may sometimofs be found co-existing

' I.e Journal Mi-ilicul /'/■(/« r-xa, Octoljcr, 11112, p. IL'I!.

f) ^ I

l'Kltl'< i; ATinN (>K 11 (M5S. DhJKsTIVi: Tl!.\.r !>:{

willi till' (Hie ill the ili'iiiii. mill tlii» 111, IV lif ill any |>iut i>l llio
ili^C'livi' tiiicl IhIuw till- <liii|ihriit!ni.

'I'lic ainouiit i>t' >liiKk \va^ imi csn -i^jvc in tillur patit-i 1
\\\u)M- i-asc )ui^ Im-ou iclalcd Tlie mtf i>f .In- piil-r in .he
liiNt CUM' wa-i iiicrra-t'd in fri(|iifii( v I'rom (is to n», forty-
\i\v mimilcs aftir the |icrf(.riifitiii. ami to l<)| tliicc Iiouin
aftiTwanU. Ill the ^rcond it \:n- iiioic con-tapt at ultoiit
'.t.'f for from two to ten hour- after the on-ci of ac ilr
Nym|it(iiii-.

Ill iiriihcr instance was there any hi-tory of -hivering, wliieli
is <le-,eiihi(l liv |)c,

(ioodall as un" initial l90I.December

>yiii|>t<)ni in at ica-t

:.'!> per ( cut . of his cases.

The dia^jiiosisof tln'se

|teiforations in tiic

course of enteric fever

is not always .asiiy

made. Patients siilTer-

ing from this dixase

frc(|ucntly complain of

alu'ominal |iain. This

has occasionally been so

severe that an explora- ,, , ,,., ,,. . ,. ,, ,

' lii:.2s, llii' l.iuiicriituri'iittcr rril nation

tory operation has l)ee,. ;i,„l i ii,,.,;itinii Un- Tviilmid |',.it..i,itini

performed. l)ut without I'erloiMiioii .Iminyr plapso (t.ntli .la\

any lesion lieing f.mnd '"'-" I'"'- "'''■'"''"•'• :> = '""'"•

to account for the
synvptom.

The signs on which chief reliance should lie placed in making
a diagnosis are local pain and tenderness, with rigidity and
fixation of the abdominal muscles and disappearance of tlie
liver duhiess.

If there is a (h)ubt about the presence of a perforation it
might l)e well to jjcrcuss the hepatic r<'gicn on each examination.
A gradual diminution in the norm.il liver dulncss woulil bo
very significant. In one of our patients the latter sign was not
evident five and three-rpiarter hours after the perforation had
occurred, and you must not wait for it.

A sudden drop in the temperature in the absence of

lo.:iu ii.iii.
|.. ISO.)

UccciubtT 4. (<'asi

IS4

THE ACUTE ABDOMEN

I f-'

liaMn.nrlmg.- is suspicious, but there inav be n., ehan.'e in
tins respcet for some time. °

J{arely peritonitis develops (luriiijr tl.e prc.gress of (vpiioid
tever au.l no evidence of perforation lias been found 'whilst
in some instances this inflammation has evidentiv i)reee(h.d
tiie symptoms of perforation, for which an oj.crati.m has beeji
undcrtaki-n.

1 do not think there is now any real diifereiice of (...inion
amongst surgeons regarding the necessitv for operation in
eases of perforatK.n occurring in tin- course of tvphoid fever
it IS hard to believe that there is any amongst pJnsicians of
the present day. The fact that exi)l,.rati.,n Inis n.'.t ivvealed
H IK'rforation m every instance in which the ab(h)men has l,een
explore.1 is not against expioiation ; a fatal cixhiig is assured in
practically every case if a perforation is not treated by operat i(m
As a rule the incision should be made throug'h the ri.rht
rectus muscle or to its im.er side. Suture of the perforation
should always be carried out if possible: this undoubtedlv
gives the best results when the bowel will hoM .sutures without
producing too much eoiistrictioji of its lumen.

A Fn.nch surgeon. Duval, speaks rather higbly of the
ormation of an enterostomy done by bringing the pcVforatiou
t<. the skill, and in 22 collected cases gives ](» cures to li> deaths
a l>'<ter result than has been obtained by any other method '
Owing lo the mortality of enterostomy for other conditions
i can but think that the surgeon should be very loth to perform'
this operatioji in a di.sease like typhoid, as it must interfere so
seriously with nutrition.

In a limited number of cases excision of the area involved
might be necessary, but. as you will quite understand such
an operati.m is a severe one. more than most tviihoid patients
eould possibly undergo with any prospect of sur%ival.
I'rofcssor JJuiza.r.1 gives a summary of (i(i4 operations —
Cures. 1S2 (l'7'41 per cent.) ; deaths, 482 (72o!> „er
cent.). '

Examination of his statistics shows that the improvement
continues as regards results of operation for tvi.hoid perfora-
tion, and the mortality diminishes yearly.
Taking five -yearly periods :—

1SS4— 1S8!», <J0 per cent. ; 18S9— 1804, 8G-3G per

PERFORATION OF UL( ERS, DIGESTIVE TIl.UT isr,

cent.; 1S!)4— 1M«M». 7j(i:! piT cfnt. ; l.s'.MI— l!M(4, (i!|-
pcr cent. : J'.MU— ]!»(•!». c.ld;} j,,-!- ,.,., it.
From u >tu(ly of cases ..pcnilfd on w». |,,nn tliaf rccovciv
m.iy follow—

(1) 111 s|)iti' of tlu" (lc>j»cral(' coiulitioii of tlic paliciit ;

(■2) liisjutfof tlu'supiTvciifionof coiiiplicatiousiK'C'.'ssitatiiig
otiicr uiKTative assisfaiKc ;

(3) 111 spite of one or more relapst's of the fever.

Openition, to l)e siiceosfiii. must I.e early. Vou must not
wait too long for recovery from collaiise. .Xriii-tn^iig siy.> that
in ten operations performed .luring the liist twelve hoius tliere
Mere four recoveries ; hut that in ten done during the >ecoiid
twelve hours success was only once obtained. All thox. died
which were opi-rated on twenty-tour hours or more after the
onset.

Ashurst states that two (mt of :!1 ca>es recoveiv,! in the
third twelve hours, and IS (mt of .jr. when more than thirt v-ix
hours had passed.

A curious clinical observation has been recorded by
Dr. h.yiiton.' who discovered much fluid in the pcritoneuni
of a typhoid patient in the early stages (.f the disea>e.

'I'lif at lack was aciiir. uiul Wi.lars reaction lia.l imovc.1 ii.'.Miivc
Au .,|HTatM.n was i.cilorincd. as ir was th.iuKht il nii..|,l l,c a .'.sc of
ac.ile pc.toiali.m of the ap].ci,dis. (In opcniiiu- llic alMlonicii no
(liscas(! (,t tlie aj.i.ciidix or pciforal ion of the liowcl was loiin.l. Tli,,
wliolc ol the iKMitoncuni appeared to lie n.ucli con-esled. no Ivnijil. was
pivsent. I.ul a consideial.le .|uantilv of alniot clear tinid e>ea|ied
t hroiiKli t lie nicisiou. The wound was dosed, and t he jmI i. nl iv,-o vered

alter a typical attack of t yidi.ud lever. The h„r,lh,s t,/,.l,„.s„s wa> I al

ill the tliiid.

This iinding of u large (puntity of lluid in the peritoneum of
a typhoid patient is very unusual, but its possible occurrence
is a thing to be i membered. as a somewhat similar condition
was found in a patient subjected to an operation for tviihoid
perforation by .Mr. Oordon Watson.

.V female a-cd II— the tweiily-sJMh dav of lli,. .Uhmm.. dp,. ration
about an hour alter the lirsl symptom. I»ulne>s in Hanks when liiM
examined, and • tiie al.doinen al.soluiely full of fluid ■ when opened
Hcer IS indies from the valve: cl..>ed with sulure. IVriloiieuni
everywhere injected, but (iiiile j;hissy.

' Tiuii.-actioiis uf the Jlodical sorittv. LouJoii.

I

im

I.S(i

THK A( ITH AI'.DOMKX

It is evidfiit tliiit (liis cfTusioii liad ))ccm present before tlio
sij^Mis of |.erforatioi) were iiiaiiifesled. The seplie fluid from
the Ixmi'l Mould therefore l)e eoiisideraMy diluted direct Iv
it entered the jH-ritoiieuiu.

TiiiKiiciLufs I'lckr

OV THK S.M.U.I, InTKSTINK,

1'iie occasional perforation of a solitary tuhercnious ulcer
of the small intestine i> sometimes encountered in an operation
for peritonitis, the nature of the idceration heinjr pn.ved by
microscopical examination after removal hy t"\cisi„n. j'n
some of the cases there is no liistory preceding tlu- perforative
symptoms, and nothing can be found at the operation pointing
to the causation of the disease. Cruise' gives an account of
thirteen instances of intestinal perforation fomid in 47,->
necropsies on patients who had died from chronic pulmonary
tuberculosis. Ten of these were complete, into the general
peritoneal cavity, and in tlie majority the symptom" were
characteristic, commencing with suchlen violent pain and shock.
The shock may be (j[uickly fatal, or an acute peritonitis mav
develop. Cruise says that in live the symptoms were most
indefinite, two having absolutely no abdominal symptoms; ho
came to the conclusion that jK-rforation of the intestines occurs
most commonly in chronic tuberculosis in from 1 to 5 per cent,
of the cases. It is never possible to diagnose with certainty a
partial perforation, and the existence of a local ab>cess due' to
])erforation can only be diagnosed when the mass can l)e felt.

In any case, when the symptoms and history point to a
l)erforative peritonitis, special attention should" be given to
the ileo-cjecal region, for here we find not only the perforation
in cases of latent typhoid, but also in tuberculosis. If the
perforation is not found close to the cariiin. follow the small
intestine upwards, and go slowly, lookinu for any change from
the normal and for the presence of fluid, which may be seen
flowing from the direction of the opening.

If nothing is found in the small intestine, examine the
sigmoid. Professor Lejars ' mentions a case in wliich he closed
a flstula remaining from an enterostomy for acute obstruction,

' Ami'r'icni hi)irii(il 11/ the Mid. Sir., lull.
- •• rrirrnt SuiLjiTy.'' p. .M I.

THRFOFiATTOX OF ILCFHS DKJFSTIVK TI!A(T ls7

iiiul two (lavs afliTWiuds llif imtirnl died tiom aciilc jx'iitoiiitis
(hic lo jK'itdratioii of a solilaiy IiiIktcuIoii^ i)la(|ii(" low down in
the.' sii;iii(>i(l. It is ill tlii> rcj^ioii liiaf pcitmatioiis of iiilotinal
(livorticula aro found.

Mr. Liom-1 Noibmy showed a paliciit hotore the Clinical
Section of llic Hoya.i Society of .Medicine' for w|„,in |„. |,,.,(i
operated for perforated tiiberciiloii> ulcer of the small intestine,
and 1 am indebted to him for the accompaiu in.' illu-ti-itioii
(Fig. 2U).

•il :!!l, wild j;avc a lii>tc>rv of dccasional

m.'K^Ht

. •-'!». IVrf(iratiMMot'l'iilMTouIuu> I'
^iiiall liitfstinr. l'r,,l„. j.!;,,,.,! i,, tli
Mr. Niiibuivs rasi'.

i>lii'miii.'.

Till! iiatifiif was a iiuiii
attacks of f])ioastii(r
jiaiu. He was admitted
light liouf.s lifter tlas
onset of an acute abdo-
iiiiiial jiaiii, cliiefly fell
in the lower alidoiiieii,
wliieh doiilded liim ii|i ;
lie vomited later. On
examination, after ad-
mission to St. Thonias's
Hospital, there was
tenderness and lifjidity
of aba<)meii, chietly in
the lower lialf. Tem-
perature, loo ; pulse,
JiMi; respirations, 2n.
AhdoiiK'ii otherwise
normal. Ojieration nine

hours after onset of syiniitoms. There was a small amount of free (lui.l
and lymph m the abdominal cavity, but no free gas. The aj.pendix and
stomach were normal. A hard sw.dliiig was found which iiivolv.d th<-
i*inall intestine 2 feet from the caeiiiii ; this n.urowcd the lumen of the
bowel considerably, and there was a small perforation in the wall of
the bowel in this situation. Four inches of tii,. il,.,iiii with the ulcer
were resected, and an end-to-end anastomosis p.'rformed. Dry spoii"-
iiig ()f the pelvis and closur<> of the wound without drainage. The
patient recovered without any adverse symptoms. MicroscoiHcal
examination proved the ulcer to be tuberculous, but no other <'videnco
of intra-abdominal tubercle could be found at the time of operation.

The state of the parts around an uleer such as this does
not permit of the simple ajipiieatioii of sutures ; it is necessary
to excise and then perform anastoinosis. in order to o1)tain the
best result. The surgeon will, however, be guided by the

! Sr

Vcii. IV., I'.iii, N,,. ;i, p. .lo.

I8.S

TUF: ACl'TK AliDO.MKX

iHiH

local coiKlit..,!. and ^MMirnil >tatc ..f tl.c palicnt ; I,,- miirl.t
fn:.! i( iM.|,„ssi1,l,. 1,, <in inoiv f hai, pla.c a tnl.c in the inlc-tim-
alla.li It (.. tlu- a(.(|.,Miinal wall, aiul drain the [.iTifoncuni.

Till-: l»i:i;ioi{.\Ti<)N- ok DiviiiiTicri.A ui- tiik L.\iu;e

UoWKL.

.Duiin<i ivcrn) yiais the aUcntion cf Hk' |)rof,.s>inn ha- hvvn
•I'jnvii t.. th,. f,.nnati(.n ,.f divciticula ni..sllv in the sigmoid
«<'l"ii. 'Iluw. du,.rti,.„la. aiv '.,i varying si/,, and nuinl.cr. and
<• lang.'s wJMcl, taUc plan- in (linn an- ri-sp,,nsil,|,. f,,,. s„nu. „{
tlic cases (,f the a.utr al.donicn Avliicli rccjuirc surgical trcat-
mnit. Tl.c larger nuni])er of ti.ein ar.- in stout males over
.'SO years „f age. .Dr. Telling l.as Mritten a vcrv full account <.f
1 us disease, for wliuli the profession is much indel.ted to him
ilc points out that as th.' diverticulum inereases in sm it
bec(mies atrophied, until there is frecpientlv onlv a lavcr of
peritoneum hetMccn perhaps a hard dried lump of fa-cal luatter
or a foreign body and the gen-ral peritoneal cavitv. Jt will he
readily understoo.l. thercfoie. that such patientsVill be lial)le
to chrome inflammation with thickening and other chaiK^es to
which the ajipendi.x vermiformis is liable, there being a^verv
close resemblanc,> between one of the.se juniches. placed as i'(
frequently is in an a])pendi.v epiploiea. and tiie appeiuliv Jt
IS also evident that the n-sult of anything like a perforation
into the general peritoneal cavity will be a, vcrv serious thing
tor the patient. .\,.thing but early operation will be of avail
to prevent a rapidly fatal ending, these perforations taking
l)laceat a time of life when the- power of resistanc- is not always
at its best. An abstract from a paper published bv .Mr. (iordon
Jaylor will illustrate the clinieal cl-.aracter of such a case and
iiuIk ate the treatment wliich it demands.

^al]v 111 tlu- inoinin- w-.s su.ld,-nly s.-iz.-.l witli v.-.v s.-v.-ic- i.aia in

ho abdonu-n while takin, his .ai.l-day la.-al. lie h.vai.u- .^.Z . U

.^ lla,.s...l, and n-Muin-d h.-ip to rou.-li his bodroo.n. Ahnost im-u.-diatWy

attcr th.- onset ol tlu- ,,ain. whi.-h was a.-con.,,anied hv vomiting, a

o the attack !..- pati.-nt was ly,„g on hi.s left side with his knee, drawn

up on the abd.)nien. 'J'here w •.- "•ip-if fetulerno - „ . .

jutit, «... ^uat luiuemcss uii prcs.surc over the

' /.iiiu;/. V.a\, V,.l, I.. [,. vj:,.

PEHFOF?.\T[nx OF ULCERS. DlfJKSTIVT- TIJACT IsO

Mt iliac fossil. iiikI in,,-., mink,;] nitniMous li\ |mi.,.m li.>i,i Wiis present

111 tills n.-l„ll ; tlir IVs, „|' 111,. l„.||v „Mll «M. s„|,. Th.. liv,.,- ,||,l„..ss

was luMiiK.I. iiii.l tii..i,. was no cvicicii-',- ol In,. ||i,j,l ju tl,,. „lMl,,Miin,i|
cavity : tlic tciiiiiciatmc was sul.n,,rnial and tli,. puis,. u;,s |,mi Th,.
symptoms stroiif^ly siim^.s,,.,! a|.p,.n,|i,.iiis an-l lli,. possil,iliiv ol , l,.).-
skUmI appi'iulix was (.,.iisi,l,.n.il.

'l"lici(. Is gcii(.iall_v u liistofv of pain (.(.mmi.nciii^' ,.n tli,. i,.f(
sick- (.f tlic al)il,)iii,.ri. and as i,i,.si ,,f tli,. i„,ii,|i,., ,|,.v,.|,,|, in tin.
M^iii,)i(l this is lo Ik. ,.\|)(.(l(.(l, ami tlial iv-ion. in a ,l,>iiliitii|
ca-^c. shoiil,! In. cxamitK.,! lirsi. i„ th,. paper fn.iii which th,.
iihovc cas,. is tak,.ii aiiDtluT is ,i,.s,.rilH-,l. in wl,i,.h \Ur piMiili
Ma-i sittiati'd in the ascrndinii cdlon.

•I'll., patient, a man ,.f 7(1, ,li,l not n,.i ni,.,lieal a,lvi,',. until a w,.,.k lia,l
passe,!, and at that time his eomlition was ,l,.sp,.,..,i,. i,-,,,,, ,ii|Vus„
pt.ritoiiitis.

When coiisidffinfr tlic l,H.alis(.(| snppmations \\-hi,|i aiv in(.t
with ill the abdomen we ivfeiivd to tliese (hveitieiila : tlic.ir
pirsciice piohably e.vpiains many conditions which wei'o
formerly obscure. The cases of successful opera.ti,.n f,.r this
perforation are not very numeroiis. but. with th,. improvement
which has taken place in r-ir rt.coauition of th,. causes and
troalment of peritonitis, the list Mill (hiubticss increase, as
oarly operation becomes recognised by the prof,ssi,)n at largo
as the only satisfactory treatmeru.

I'ki{1()h.\ti()\ ()|- STi;ii( orai, ri.( krs.

As recently as JS'Ki the lat<- .Mr. (irieu Smith wrote aliout
stercoral ulcer: " .\lthou<:h no sp,.cial (K-crijition of this
disease lias, so far as th,. writer knows, been written, and
although it is iu)t of frcjuent occin'r,.|ice nor of gri..it import-
ance, yet its und,)id)te(l existence and i(.al oiavitv may justify
its being cla<s(.d under a. separate heading.' Ij,. t'hcn inentioiis
a few instances of intra-abdominal abscess, in which a foreign
body was found, but admits that sonu' of llu.m w<.re imrst
probably due to disease of the app,.ndi\. He writt.s : " The
condition as [ Have met with it is simply a. diffuse subp,.ritoiieal
cellulitis."' atul he evidently regarded it as always d, .pendent
on the irritation of a foreign body.

Sir ,1. Tiland-Sutt(m has given cxamj.lcs of facial abscess,
associated with small but shari) foreign bodies, in the large

I'M)

THE ACLTE ABDOMKX

iiiii

iiitcstiiif : and Dr. \l. I). H()l!c>t<)n. in ii pii|K'r on " hTicolitis
Sinistra."' gives instances in which iHceration .leveloped in
a (liverticiihini of tiie c()h>n. and jiroduced suppuration
around. Tliese ulcerations were not. however, hlce the varietv
which is under eoiisideratioii here, but come unch'r tiie
heading of " Abscess Secondarv to Diverticula of the Large
Howel.""

Stercoral ulcers l)ehave much in the same way as ulcers in
other parts of the digestive tract ; they may perforate siiddeidy
and produce general peritonitis, or extend gradually and give
rise to a locali.sed intraperitoneal al)scess. When it is recog-
nise 1 that they are usually secondary to a condition wliich of
itself is seriously threatening the patient "s life, it will la-
ap|)reciated why they prove so fatal. The patient, who is
most frecpicntly sutVering from chronic intestinal obstruction,
caused ))v carcinoma of the large intestine low down, appears
to have his last chance of recovery taken away if a stercoral
ulcer, perforating suchK-nly, floods the peritoneum with the
very septic contends of the bowel al)ove the obstruction. In a
patient already weakened and distres.sed by the ol)st ruction,
this additional attack ;s usually more than can be successfully
combated, and ]> jves fatal in a few hours.

la May, 1912, I saw a youiij; ami stroii^i-Iookinj; man with Dr. A. K.
(iodfrcy, of Fiiirhley, for a swclliiij; of tlic liver wliicli we considcrod to
be secondary to a farciuoiiia of tlie larfjo l)owol. wliidi was prodiiciuj.'
few sytnptoms beyond eonstipation. We advised the ])atient to liave
notliin;.; done in the way of operation nnlcss more nrjieut syini)toms
deveioj)ed. A day or two later another medical man was called in by
.1 relative. He gave the patient a small white powder (.' calomel), anil
within fonr hours after takinjr this a;nite peritonitis with crdlapse
develojied suddenly j.nd death occurred within twenty-four hours. I
have no doubt that a latent .stercoral ulcer had burst "pndiably as the
result of a violent purgative.

When any one the subject of chronic intestinal obstruction
of a mechanical kind complains of sudden increase in abdominal
pain and has a rise of temperature, not necessarily a \-ery high
one, the possibility of the giving way of a stercoral idcer must
be remembered. This possibility is increased if there is. in
addition, an excessive sensitiveness to palpation. ])reviously
absent, but perforation may give no immediate sign of it's
ooourreiice. as in the following instance : —

11'

I'KHFOHATroX OK ILCKltS, DKIKSTIVH TIJ.\(T I'M

Siiini- yt.-ars nj;i> I Wiis ;isk<il l>y llif late Mr. ('. Miuiimii L.wis. iIicti
of Sti'viiiiig. to iM'c n lady with liiin. «lio liail cairinoiiia ol ilic nciiiiii.
She was over 80 ycaix ol a^'f. aiitl liail only sent lov lijiii ili^ii inoiiiiiiii
hrcauHC her liowi-ls had not acted for a week, lie evainiiied I he alido-
iiien. found it niiieh distended and tyiniianitie. \vliil>t I he rectum was
C'onii>lelely liloeked liy ii eaicinomalous giciwlh. When we saw her
tojielhef a fiw lionis later she was Mincli ihc same, lull wilhoiil anv
vomiting. ll<r limperatuie had heen |ii(i , ijic pulse was ^ouo liul
the tongue was hrowu anil dry. Ineisioii was made to periorui eolo^iiiny
in tlie left ilia<t region, hut when the i)eritoneuiri was opened it was
found to 1k> Hooded with black lii|uid fu'cal matlei', which was >tlll
escaping freely from two ragged openings in the immensely distended
Kii.'iuoid tlexure. These openings (with thin and irregular ('dues) were
s. lated i>n<( aliove (he other in the anterior part of the hovel, wlijch
passed down hehind the middle line of the ahdomen. Pints nt llii> olfen-
Kive tiuid came away hefori' it was possible to secure the sigmoid lle\ure
to the ahdominal wall. The peritoneum was (•lean>ed as well as
l),)ssil>le. hut the iialieni ilid not lally from the operation.

Jii fills case It Is |)(i.»il)lc that tlic howcl had oivcii uav In
the iiioriiiiio, mIicii llic paliciit sent tor licr iiicdlcal adviser.
V[) to tliat time she liad for sonif days ooiio on. takinj^ dosu
aftrr ilosc of iiu'dicinc witlioiif relief, whilst the iiunicnsi-
acetimulation of fu'cal matter h])ovi' the constrietion had
caused iwcessive streleliiiig and l..;al injury to tlie bowel, wliieli
liad ended in aeute haeteiial necrosis. Tlic necessary removal
from tlic ))cd to the operating table may have ojven risi' to a
further escape and difl'usion in flic peritoneum.

Treatment <,i this most unfortunate complication should be
directed to the cleansing of the peritoneum, the insertion of a
I'auPs tube in the opening from which the fa'cal matter is
escaiiing. and the siitining of the damaged bowel to the |)art
of the abdominal wall most I'asily reached. Strain on the
Mall of the bowel, usually softened and easily torn, must be
avoided. By this means the opening will serve as a colostomy
opening and the obstruction lie relieved. The dillicidtv in
cleansing sai.siactorily the foukd iRriloncnm will render the
jirospect of recovery iloiibtful. Yet success may occasionally
be obtained.

• In March 27, 1901, 1 saw a patient in consultation with lir. S.
Fauleoner Wright, of I.cr. He was 71 years of ai;e. and stated that he
liad always been healthy until the 21>t of that month, when for the
first time ho exporieiiced abdominal pain. Tliis was accompanied bv
vohiitiiig ;uiu cunsti[)ation. :-rim'c that liin.- the pain luid couliiuied

'&

II i.

]<.)-2

TTIK .\( ITK ARDOMKX

witli o(c;i,i..iiiil vomiting', .'mil tin' l.i.wcls liad not actt'd. '111.. abdiimcii
was imich distomlfd and tyiii|(aiiitic. ilin noli- ariiuiid tlio ;iiiiliiliciM
lii'iiif; lii;;li pitched. 'I'licn' wiii im diiiiiiiiitidii of tin- liver diiliiesH. and
nil evidence of free fluid in ilio peiitonenni. The tenderneMH was not
extienie. hut lie winced when touched. lli< ;;eiieial condition was fair,
and the feinperatiire was normal. An incision was made in the middle
line IhIovv the umliiliciis. cud when the iicritonenm was o|iened flee j;as
escajied. and fluid fa'i'al matter was seen coveiin;; tlie intestine in the
rci.'ion of the cieciim and extendiiiu into the jielvis. This had come,
ami was still escajiini,'. from a steri'oral uh'cr on the anterior surface of
the distcTuled ea-ciim. wliiili had recently jriveii way. It was hnjje
enouLdi to admit the litth' linger, and its outline was somewhat inej,nil;rr,
with a tiiiniicd ed«o. Into this a Paul'- tube wa- issed and senired!
the ciecnin lieiiiK sutured to an incision in the rijrhi iliac rej;iou. After
the liowcl and iieritoneum had been cleansed as thorou<;hly as possible,
a l<mi{ drainage tube was passed into the ju'lvis and the median wound
was sutured. The small intestine was jreneral'y adherent, coil to coi!.
and fixed in the posterior part of the abdomen, evidently the residt of
an old attack of p;'ritoiiitis, the cause for which was not ascertained.

I'nder the skilful mana^'ement of Dr. Wrii^ht the patient recovered,
and was abh' to ^o daily to the City to business for several years after-
wards, when h.- died from an attack of broiichitiN. The artilicial anus
never closed coniidetely, and gradually, as time went on. this ..j.cnini;
became mole ini|)ortant. until hardly any f;ecal "-.itter found its e\it
by the natural anus. The patient wore n llaf. ■iiciilar indiarubber bau,
containinj; .i lai-je flat siHmtre, littinj; aecura' to the abdomen over
the artificial anus. The dieting had to be \ , carefully arranged, on
account of occasional stoppages, which, when they c,. ciirred, caused
coiiMderabh' ])ain, only relieved by the <'scapc of fa'cal matter by the
artificial opening. His general health was afterwards excellent. What
the nature of the (distruction was in this case it is impossible to say ;
the folding of the peritoneum and t'.ie condi ion of the patient madfi'it
inadvisable to explore. The complication of perforation was such a
serious one that the clear indication was to deal with that, more espe-
cially as its treatment was calculated to give relief to the obstruction
which w-as responsible for it. The cleansing of the peritoneum was no
doubt aided by the limitation of the fouled area in conscf(ueiu'(> of tli(>
old intestinal adhesions. The after history of the case is instructive,
inasmuch as the obstruction often recurred, and a '• safefy-valvt^ "
action permitted ot relief on each occasion. It was thotiglit at the
time of operation that the obstruction was caused by a ring carcinoma
of the sigmoid flexure, the growth of which is sometimes very slow ;
anyway, the case is a most instructive and encour.Tging one.

It may perhaps be possible to suture the perfoiatioi.s. and
afterwards make an aititieial anus in a more favourable part
of the large bowel.

Perfoeatiox of Steri okal Uloeratidn associated with
ObsirU' HON OF THE Larue IJowel. — A case was admitted on

1-

I

PKHFORATIOX OF TM KHS, DKiKSTIVK TH.\( T I'.'.-J

March 18. 1913. .-jud surn-ssfully op.Tatrd oii l.y Mr. Stewart
Ri)iu|ii('ttf.

• i. <".. ii man of 01 . coin iilaiiicil of paiu on t li.' ni;lif .-id.' of i h.. al>d(>iiii'ti
for ix weeks, luit threo d;iys liefoie it w.is wor-e and lie wa^ doiilded
up l.y it. He ind vomited .iinl was evidently siilTeiiiii.' fn.iri ol.si met ion.
Tlio abdomen moved well on respiration ; was more or le-> t vtni.aiiitie
on perciw:4ion ; rather tender in the ri^'ht lower halt, willi m.mi- riijidity
of the rectus. Temperature, Utts ; piil-e. (,J. Notlilni; eunld !»• teit

p«r rectum, and the howeU were not aetinu'. Mr. I! |iieite. .-, h,, iii.,de

.in incision thro-sh the rij;hl rectus mti>ele, found Ire.' yas in the
peritoneal cavity which had escaped tlii(>u,'h two openin-s in the
anterior part of t'.c cir"um. The ca'ciini was iiiiieh di-ieuded. the
opeuin^is small, with thin edires ; veiy little fa-cal matter had eseaped.
The wall of the ea-cum around the openinus appe.ired iioitnal. The
ojienings were clos"d with silk sir ures. The appeudiv was removed.
A circinoma of the upper rectum was found, and a cidostomy performeil
on the left side.

The ii«ht incision iiermitted a diseliaiKi' with fa-eal odour for al.out
seven days, luit theiiatient left on Ajiri' 21 ilia very fair c.uidition with
the I'olostoiuy wound aelim,' (piite satisfaelorily.

It appeared piobahht that the cajcum had ;;iven way during' remov d
from bed to *heatre.

" Stcrcoml iilci-r '" is one of tlio m<)>t scrii)iis coinpl'oatioiis of
olfotiic iiitfstiiiiii ob>tnictioii. even wlicii the peritonitis pro-
(li'ccd is puri'ly local in its (■Jia-actiT. If tiicic is an ilidctiiicd
area of duliicss in tlic ca'cal region, -with tenderness and a sense
of resistance, Avhilst rectal examination shows an a|)parent
thickening on the right side of the pelvis, this coinphcation
should be siispeeted. Fluctuation may be found if the case is
seen at a later stage. Shoukl the patient be fat and ner\ous
the diagnosis may be very difficult ; even with the assistance
afforded by the adinniistration of an antestlieiic it may be hard
to say that tliere is miicli wrong with the side really affected.
There is notiiing like tiie definite indiu'ation wliich is found in a
case of localised inflammation or suppuration secoiidaT-y to a
disease of the ai)pendi.\ wliich it resembles closely in some other
respects. It comes on in a person suffering from intestinal
disturbance ; the pain is in the right iliac fossa., and i^ accom-
panied by increased distension of the abilomen and a rise of
temperature. Tenderness is more marked in tiie right iliac
fossa tiian in other parts of the abdomen. Yet there are
difference.s — a stercoral ulcer, giving rise to a localised extravasa-
tion and abscess, is .specially met with in ekleriy fciualo who

A.A. O

i!t

hi^

9S!

194

Till-: A( ITK AHDiiMKX

ii\\v ii liistiiry I'f cliriiiiic cim^tipatinri. rr('«>iitly nutn- obstinate,
uikI associivtcti witli " wiml in tin- >t()niiuli." Tlii' r\>v of
tfni|U'ratiiic is not j;nal. iind tl;c iina of tciuU rnf>s i not so
easily loialiscil as in a|>|M'"i(li(itis.

'I'l'u' rollcition of tini<l fifccs wliicli forms in tlic |«iiton«»ini
has a tiMulcni'y to spn-ad latiially. for it is no< (•a>ily localised,
us it escapes readily, ami it may hi- tlie operator will Iind it
up to or lieyond the midille line sl.onid lie make an exploratory
median incision to lir-l out the exact siti- of the ol)>tr'(tion
when there is a douiit. Whether he thus disco\ers it hy
accident, or maUes direct or intentional incision into the
abscess, aeounter Dpeninj;; and the insertion of a larjie drainage
tube will p-ncrally be re(|uired. If the openin;.' in the ca'cum
be found, a tube should be passed into this, si Miat the contents
of the bowel, which rapidly come away, m:.y be con<luetod
beyond the abscess cavity. These contents, pu> mixed with
tiuid fa'cal matter, are < xtremely olTcnsivc. more so than most
abdominal collections of ,i pvuident charactiT. aiulthat is >aying

a great di'al.

rndertlu st conditions the prognosis is bad ; thedischarge
of large (piantities of fa'cal matter, with an increasing admixture
of pus. causes much local irritation, and mayeiul in raj)idexliaus-
tion. Should the inflammation sul)side and an artilicial anus
form, it is not placed in a convenient position, and may lead
to idl the disa('' antages of an opening on the right side — that
is, if the ol)struction becomes complete. The ease under the
care of Dr. Wright suggests the possibility of a more satis-
factory course of events, thi' opening acting as a safety valve
when retiuired by the temporary stop|)age beyond, and causing
but little inconvenience in the intervals. Another danger in
these pel f oral ions is the tracking u])wards of the pus and the
formation of a large collection in the sub-hepatic or sub-phrenic
regions ; a secoiul incision would be required for the better
drainage of this extension, but exhaustioi\ from the discharge
would not unlikely prove fatal. It will be evident that
recovery from these collections will take some time, during
wliieh the original cause of the trouble — probably a malignant
growth — is increasing in size and becoming more difficult to
treat radically.

Tlie establishment of a short circuit between the small

I'KHFOHATION oF rL( KHS l)|<;i:s||VK 11! \( T I',*.".

Ix.Wfl anil tlif lariif Ixy I tlir ^In.llliv \v..ill.| he tlir III. il

n|MT,llii.n, lillt il i- tinl nlli'ii thai till' M|.I|( ,|atr ..) tlir

aln|..lllcll allnw, llii, to Im' iloli.'. Nc.ll railliMt <|n II al llir fir,)

oprnUlnli when llic n>ll(|il i< >|i ul Ihr jiallrlil |, l.a<| ami llir

••otnplicalinn a very -fiinii> i.tic, |iiTlia|>~ <>t .niiMiliralilr ami
ill ilrliiii'd .•Merit. Laid- ilir i, -nil nt a. |.rnlon;r(-l >.|.iif
ili-rlijir).'c niakc^ il \(i\ niilik.|\ thai ih.. Mitiin'^ ni|iun(|

wonlil holil .iftrr ihr j liim ha.; I.r.n <ri,M i..! ; hiit y in-t

jn<lu(' ciicli cjiM' nil iN nicfil--.

.Mcs>i«'ur- Cliailiit and 'I'linnia— I ' >ay thai when the lir;ri'

Im.wcI jiivc- t'foni vi.ftcninj; of it, < |, in ruv.., of .il)-ini(ii,,n.

IIk- lll|lfllfc i- fuumi at the jnmllnli ..t the a-rrmlin;i colnli
iuiil (NPcnni to the outer >i(le of ihe loii^ilnilinal han.l. The
>eeon(| v.iiiety. or j.'aMt.'renoii^ pet t'oial ion i~ fonm! in ihe left
portion of the eoion ; it i> generally -oliiaiy of -niall .-i/.e,
with «aii^fenoM> eroded edjie-;.

' In/,. U,-H. ,1, II,,,- , lull.

U J

ti:
I if

\¥

I'AHT IV

A«UTK (ONDrnoNS llWINO 'n'.KIH (UncJIN IN
TIIK IK.M Al-K (JKNKKA'nVK OIMJANS

S.M.i'iNtiiris. Tvo Sai,i'Iv\. K\ru vU tkkink Gkstation.

SKV'KKAr- ooiiilitioii- ot flu- fiir iilc p'ncrativo nrjiaiis may be
lightly t'onsidcrrii imdrr the licailiiii; ol tin- " iicufc iibdnincn " :
'"he s|)rcail of mi iuftctinii tlinmuli tlvt- Kallnpiiin tub's, th«'
iai»tur«' of a pvo-siiI])inx. the niviiifj way of the ^ac of an
j'ct(.j)io jjcstatioii. m-croNis of a snbjHritoiu'al iitcriiu ibnitl or
tho Uvistinj? of its pciliilc ; also aiciilciits attfiulmg the growth
of an ovarian cyht .

(1) Infiction throiiijh the 'riihi't. etc. -An aiutc, urRfnt, and
occasionally fatal illness is sotnctini'-s |»roduccd by the spread
of a t'onococcic intlamniation from below. The tubes not
liavin;; been occludc(l by a pre-existing intlamniation. it is
pos>i])le to see purulent tfuid coming from one or both of them
\vhe:\ they are lifted for examination.

TliJH wa- tin- oa.st' in a yoiiiiii iiiiiiricd woman si-cii with I>r. Fitz-
gcrahi Ai'iitc :il)il<>iniiuil Hyiuiitiiiiis had coiiiiiiciu'ed tlirfo days
iK'toie nd the iiiilHiii wiis very ill witli quick i>uls«?, aluloitiiiial piiu,
iUid di> . usion. She liiid siitlVrcd lioiii a Viiimiiii discluirgc lor tlin-o
weeks. At tlie oiMMulioii tliiMC was puiilk'nl petit oiiit is in tiie iielvis,
witli aciiicly iiitlaned I\i1m's. The pelvis was .'leuiised aiitl a draiiiap^
tulie Jill III afterwards. Lioih tubes had to he re'iiovod, l>ut jsart of
one ovai> was let. She made a satislaetory recov-ry. Tiie origin of
I le disease and its nature wore easily proved.

It th' svmptonis are severe and cause anxiety, in these ca.scH
it is beticr to o|)crate, for, altiiough the intlammatory condition
settles down in most, a chronic disease of the tubes will remain
and re|>eated intlammatory attacks be the ruK-. There are
many more lives eri|tpled ;in<l spoilt by chronic salpingitis than
is usually acknowledged. It is not advis.blc to remove the
ovaries, nor is it always necessary to remove both tubes.

lu other infections by bacilli, such as ; ierpt-ral, strcptu-

• '*»TJ*/^-.7P

DISKASKS (iK IM-MAM-: (iKNKHATIVK n|{(; ANs it.T

n.criil. or iiillii.li/... I lli. ..yiM|.l«.ih- will !»■ Miml.i iii.l i.'i|iiii.'
|ir<iin|»t Ir.af 111. Ill

111 |)ii.-r|>< i.il iMiiioiiili.-. 111.' iii.wl ,i.ii\, ,,t the ..rL'aiiiMii>
|»r.-. Ill IS III.' ^h) pliH'nrciii i,i/n,f>),i ., wliirli liml.. ( iifraiiiT
lliriMiirli *..iii.' I.ica.li ..( >iii»ii.f III till' y.iMtal liii. I ..r |..i-m's
.lir.'.'tly l>y way <>t llir |-'all(.|iia:i liil.o. thi' int. t'tioii JMiiiy
..Illy t.M. .'..111111. (Illy r..ii . y.cl in lli.' fir>t pla.'.' I.y lli.' ,iii. n.lant
at Ih-' .'..iiliiiciii.'iit. It it tiip', a...'** t<> tli.' pi-Kix |,\ u^,v ,,t
III.' Kall..|>ijm tiili.'s. a |i.iii(.iiili« ,,| .jr,,.! mi.ii'ity .|Uii kly
.'.iiiiiii.'iiccs; 111. -kily till' Mat 111'.'.. t • cliilij-li.-l t.'\.'r " i> u'ciicraU'v
r.'.'.tjjiii.fil. anil the pr.'caiiti.iiis now lak.n nm!.!' ilic .li>.';i«.'.'
a I'.iiiipariitivtiy nir.' one.

Tin- iiivasi.m ..f tin- -.y-t.iii I.y iji.' ,in.pt,,c.„'.'i m thi, .li„.a>.'
i> usually inarkr.l hy an atta.k <if >lii\ .lin;.', ..r a rii.;..!' ami
rapid rise ..f tcmpcrat iir.'. with iiiii.li in. i.'aM' I piiis,-rat.'.
Any .lis.'liarn.' wlii.li may l».' pr.'x'iit i».'.'.mi. > ..JlVn^iv.' 'rii.n-
i.'^ al»i!..niiiial pain in tli.' h\ p..;.'astrii' r.').'i.)n ..t \aryinv m-v.iiIv,
Miin.tini.'s viiniitiiii: an. I usually ..tl.'ii-iv.' .iiarili.i'a.

'r.'niU'rncss in the liyp.iL'astri.' r.'^'i.m sprca^U an.l is -oiii.'-
tiin.s very acute. The altil.tni.n bec.im.s .li.sten.l.'il riy.>r.s
rei'ur ; the temperature li.c.ini.s .it a pNainie Ivpe, iliere is
pr.tfuse .sweating' and cinipl.t.' an.ir.'xia ; th.' .liarrli.ea is
tniulile.s.iine ; deliriiiin is pre^'iit at niL'lit ; and .'X i.lenc.'s ..f
secoiulary mischief in th.' luii^s. pleura ..r pcricanlium <.r ..tli.'r
ii'iiintc parts (lev. -lop. and th.' patient .li.s .■.\liaii>tcd. J)ulh.-s
iniiy I).' toiiiid ill the Hanks as a result .if th.- ...Ik ■ ti..n ..f tree
tlui.l in th.' periioneal cavity i.r a e..n>id. rahl.' . \u.lati.m •
the suhperitoiieal c.'llular tissue, espeeially if th.' iiillammati,.ii
has s])read hy way of the lymphatics.

The treatment should he in the lir>t place to .lisinfc. I the
uterus and vajjina. to tak.' away remaining' dt'hii> of placenta
anil decoiuposinji clots. t.» remov.' infect've flui.i which has
a.cuiiiulated in the |)clvis. and po^sihly in th.' Hanks, an.l l.i
|)i.>\ ide good pel\ic .Irainau'c.

It is wi,se to In'gin the a. ininistration of anti>tre|itoeocci('
serum at once (tiie u^ual slock ■ polyvalent ' pr.'paration) and
continue this treatment with a vaccine prepared from tluid
i-cmovc.i from tlu' peritonenni at the o[)erati..n.

In cases where the uterus has heen ruptured, jicrtoratcl, or
is extensively infiltrated, it inay he a:is;sal)le to reniovi it.

ins

THE AClTK ABDOMEN

;h'i

Thfsc cast's arc always m()>l serious, and rctiuiri' energetic
treatment from the commencement. Tliey are not all of them
of the fulminatinu variety. Init it is important that the milcU-r
cases should he treatcil with decision. In pcrforminu the
needful dressintrs after operation, ami in douching, etc., the
attend oit should use sterilised ruhher jrloves.

A careful watch must I).' kept for the dcvelopnu-nt of secon-
darv ahscesscs. which should he evacuated as soon as they are
found. If i)ossil>lc a local ana'^thetie should he used, or <.fa>
ami o.wjztn : they nuist not he |)ermitted to attain any size.

{■2) hiipliuc of a Pjio-sdl iiiii.v. The followinji ease will illus-
Irate this accident. It is tlie account of a patient adniittel for
acute ahiiominal symi)toms. It will he noted that there is a
certain amoinit of similarity hetween tiie .-ymptoms caused hy
a ruptured pyo-salpin.\ an;l those due to a ruptured ectopic
L;c>tation.

\VI1H II Ml' I I Ml 11 I 11' M l\\-l-|» liw>» n. ■ IL 11' 1 I'. ' ........ ^

acciHiiiI el iiiiliui'.-liii.i i>t inilftiiiiic ciiaiai-liT some years ajin. 'I'lii'ie
hail Ix'cii iMotiiM' vaginal iliscliari:!' Im- siniii- iiioiillis, anil tlic iiiciistiual
licriml was a tori iiii.'lit (ivrriiiii'. 'iiu'Vi' had ln'fu no aclion ot llif
liiiW'ls tor two ilavs.

Whiii -icn with l>r. II. Markciizic late in llic atleruoou I he patient was
lyiiiii on hiT liark. looking vi ry ill anil ana'iii'c. anil sceiiieil coihiiistMl.
iirow>y. anil aiialhelic. 'riiiTi- was a small riiv ular Hush on earh i-hi'i-k.
'riic skin was iliy. 'Ihe lopiiiit ions wire sonii-wiial iinickeneil (Jl).
anil the imlse was Ijn. 'I'lie IrnilPi'ial nre was |U|-4 . .she i-oini>laineil
(il pain II llie aliilonun. wh rh was founii to 1)1- niovinj: ipi'tc well in the
nitpiT lialt. Imi was li>s niol'ile ihaii iisnal in the lower part. On
palpation there wa- ininli coniiila'iil ot tinilei ness. es)ii'rially in the
lett iliae nuion and li^'lit up lowanU the liver. Nolliinj; almonnal was
tonnd : the ahdominal wall was i|nile withonl rigidity, and otVeied no
lesistani-e to iia'i)alion. tin peii-iis>ion the note over the wliole ab-
domen, inrlndin'.' tin- liv.M-. was normal. .\l .").;!(( abdominal exiiloialion
was i-anifd out ; an ineision was hrsi made in I he epi';a.-~l i ii- lejrion. and
ihe ^loniaih and iliiodennin ivamined. 'I'lie liand wa- then passed
ilownwaids to the iliai' tos^.i and ajiliendix leuion and onwards lo the
.w.lvi.. onr.iiis A liiniour was li'lt to the let! ol the uterus. 'I'liis wa.s

A tumour was li'lt to the let! ol the uterus

lid il was ihoUfilil ih.ii a rupture of tliis

pelvie oryan

reeoi;iused as a pyo-saiiiin\, a.. „ ,

would ariouul tor tlie condition. .\ .seionil incision was made in tlie

DISKA.SKS (W FH.MAF.K (iFXERATIVK OHOANS ]W

midtllt- line above tlio pul)<'s, and wlicu the ])eiitoneum wa^^ opeufl,
tliiu. Moiuewliat viscid, odourlesx pus was found, exteiidini; Ironi llie
pelvis into the tlMnks. The intestines were ])a('keil oti' willi strips of
stetilist-d trauze, and tlie p,vo-sali)inx was icuioved after tlie ai)plication
of three (No. 4) silk ligatures. 'I'liere was no inllainination of tlie peri-
toneal ('<)at of tim intcslitie, and no lyiiipli was seen. The area of
inteetioii was cleansed with moistened s])onjies. ami drainage was
provided h.v a rubber tube and a strij) of jjauze. The ri>:ht ovary was
somewhat fixed by adhesions, which were freed, but it a]>peared to be
health.v. as did also the tube on tliat side. The tipper wound was
sutured in layers by Mr. Hietsoe, the house siirjreon. whilst (he pelvic
condition was beinj: treat eel. The pyosalpinx formed a tumour of tiie
size of a hen's ej:f:, the walls of the Fallopian tube were much thickened,
and there had b»>en aru])lTire not far from the ostium abdomiuale. wliiclj
itself liad been closed by adhesion to the broad li>:ament. The ovary
formed part of the inflammatory mass removeil. and could only be
<listini;uisliftd on dissection. Tlie l>luf; was removed on the 24tii ;
there was a small amount of clear dischaifie. The bowels had acted
twice. The pulse was 70 and the temperature was normal. Pain was
(piile relieved. She projiressed satisfactorily, and left hospital on
Marcli 13.

l'yo-sal()iitx is rccooiiiscd as .lie mo.^t important coinlition
fziviiig rise to j)L'rit<)iiitis liaNing its origiii in the pelvis, rcpt'ati'd
localised attacks bciii^ coininoii. As a source of ditluscsprcad-
iii>I peritonitis it is k-ss t'n'(|iicnt. for tlic tliickciu'd tul)c docs
not often ruj)turc as it dul m this case and alkiw tin- purulent
contents to become ditTused. 'J'liere can be little douljt that
the izonococcus is extensively spread l)y the rupture of a tube,
aiul althouirh J)r. Dudj^eon' and Mr. Sargent coinduie that it
possesses a slii;ht ])athogenicity when introduced into the
j)eritoiieal cavity, it does proiiuce a peritonitis which may be
ultimately tutal. \V(> must en(ha\our to ojieratc before
peritonitis l)ec(nnes exteusive. The prognosis is thereby im-
mensely imj)roved. and the duration and severity of the
illness diminished.

None of tliose who saw tlie extent to w liicli purulent dilTiisioii
had taken ])lace .n this ])atient doubted that general peritonitis
must have ensued bad operation i)een delayed. It was tiie
aspect of severe illness, with the history, which induced Dr. H.
Mackenzie to suggt'st the desirability of ex})loration. for local
signs of the gravity of the attack were absent. There was no
trace of protective- rigidity of muscle, whilst the tiiidcrness

' ■• The Hactoriology vl IVritdiitis." |i. .".;),

i

2<tn

THK ACl'TK ARDO.MKX

III. ,

found Av.'is not in any ^va}' rcni.arkahlc. IS'otliinji indi'^uU'd tlic
])ro)»iil)I(' origin of tlic syniptonis, and altliouyli the (■))i<;nstric
region was cxjilorcd this was in dcfcivncf to the former history
of indigestion, with a reeent heavy meal, rather than to any
idea tliat stomach ulceration liad really given way, for tlien;
Mere no locaHsing signs. J have stated tliat the ap[)eiidages on
the right side aj)])eared to lie healtliy, and Mere tlierefore not
removed, ft was j)rol)a1)iy rigid to leave them : l)ut the result
of so doing, in a case formerly under my care, in which a l)yo-
sal])inx liad given rise to intestinal ol)struetioii. has made me
h'.ss oonfiilent of this than I might otherwise have })een. 'J'he
appendages on the left side appeared nornud, and were therefore
left, but in the following year the patient returned with
])eritonitis, th(> result of a rui)ture of the remaining tube.

A woman, .iiiod 20, was aibnitlod -)■ .auiiaiy 31. lOo.'J. Slic stated
tliat she liad lieen quite well until tlie 2.">th. when she was taken ill with
pains all over lier. Tlie .-.itaek jiasf-ed olT. but came on more seveiely
at 4 a.m. on the 25tli, and was acooiiii)anied by s(>vei»- jiain in the vijilit
hip which sjiread all over the alidonien. Cii admission the abdomen
was distended, did not move well on resjiiiation, and the patient looked
ill. 'J'he abdomen was not tender ; it was easy to examine, but uotliinjr
abnoinial was detected on piiljjation. KNaminatiou jii-r rirlitm ^howed
nothing unusual. 'J'he tempeiature was loofj , and the pulse was 1U4.
On I'ebruary 3 she had an attack of abdominal i>ain with vomit im;, there
being visible distension ot small intestine and jieiislalsis. 'I'lie bowels
acted well just before the attack. Operation was advised because it
was recognised that she had recurring attacks of obst ruction due to a
mechanical condition, but she refused <'oiis(iit until J'ebruary C, when
anotlier more severe attack of pain and vomiting induced her to think
more seriously of her illness.

Incision was made through the right rectus sheath and the muscle
lemiiorarily displaced. On ojiening the ])eiitoneum a c<)il of small
intestine was found to be distended and to iiass down into the pelvis,
which seemed unusually full. At first it ajiiieared as if the uterus was
very largo antl smooth-walled, but fuither examination .showed the
swelling to consist of ' vo parts, a softer one to the right, and when the
finger was passed inl' Oouglas's jiuuch a groove could be felt iiiaiking a
division between them. The pelvis was isolated with sjionges and a
large jiyo-salpinx. which rujituied during the ]>i(k<ss, was brought
outside, se])arated from its attachments, and removed. 'J'he pus wa«
very offensive. 'J'he ovaiy was included in the mass removed. The
left side appeared to be normal. TJie loop of obstructed gut was found
adherent to part of tlie boundary wall of the pyo-salpinx which had
t>een left behind — it was kinked from before backwards ; anotlier loop
also adhered to this part, but was not ob>tiucied. 'J'liese were freed

J)]SEASKS OF KKMALK GKNi:i; ri\ K (t|!C;\NS i'(.|

and some oiiicntiil .idlicsiou.- were ii\si> sc|i;iialr<l or divided Ipclwcrn
li).'iitures. 'I'lic jx-lvis and lower iilidointu ivcic ^v:i^.ll<■d out with waiiii
salino Kolution, and a liilx' was Iiii in wliicli <\iindiil imo l>oii;:lass
IKtucli. On llie tliiid day sonu; distension ol ihc ^loin.irli was luevcnl,
and fliirt was followed liy a nioie or less j^eiieral iiieleoii>iii wliieli
frradually siilisideil under approiiriale t realiiietil , alllioii;rli t lie jialienl
was for a time Kciioiisly ill. The tube wa> removed nti ilic ^ivenlli dii\
allei ojieration. Slie lell the hospital on Mareh N. I'.io:!.

On Oetolier 2o, l!Mi4. the i)atienl was readmitted with sym|.ioms ol
dilVilse jieritonitis. Slie had enjoyed frood health ^ime leaMin; the
hospital nntil thiee weeks hefore lier leliirn; ^he then had a iiien-i riial
period, followed a week later l>y hiemoirhai;*' from the \ai,'iiia which
lasted for three or foiu- days. This was followed hy aeiile pain on the
rijiht side of tlie alxlomen which sjiread to the left .-,ide. This pain
continued for a week, and then for the tliiee days inevioii>ly to her
coining tip it increased coiisidciahly, anil was airain accompanied on the
first and third days by Inemoi ' liaire. She had Mimiled lour time.> only
and on tlie d.iy of admission. The ahdomen was sliixhliy di>l ended lint
scarcely ii- -ed with respiialion. The letl rectus was ri;ri<l. and the
lower lialf tlie left side, (oeal tcnderne>> wa> <-omi>lained ot all over
the abdomen. The flanks wetc ie>oiiant. The j)ulse was li'ti. i,iid the
tenij)eratuie 10i> . .\ tender swellinj; <-oiil(l be felt ]»:r i;iii'ni<im in the
left fornix. Mr. .^^arirent. wlio successfully oiieiatcd, tound that the
pelvis contained pus, whilst a seio-pur lent fluid invaded the lower
abdomen. 'I'he left Fallopian tube was of the >iz<' of a thumb; its
walls were iniicli thickeiu'd and disteiuhMl with i>us. The ovary con-
tained a large! cyst in whieli was a bl I clot of the size of a taui;i'iin<'

orange. 'J'he lower abdomen was washed out with >aline >oluiion.
From ffie history of disturbed menstrual function it was thoiiuhl that
the blood clot might repiesent the remains of an ovaiian ge>lalion,
but careful examination in tin; clinical laboratoiy did not conliini
this idea.

m

(3) Ectoiiic Gtnttition. — Aiiotlicr i)aft (it Ihisstilijcct 'i • of
ectopic go.statioii and its niptiiic ii> a catix^ id the " aciitr
abdunicu "' — introduces us to additinnal >yiii|»t()iiis ; those
caused by the increasing accuinuia.ti<in nt ''luod in the ])eri-
toiieum and the elTcct of its loss fiotii the riictilatioii mi the
general state of tiie ])atient. 'Die rajiidity with which it is
poured out and the eiftct of tliis are mi grrat that tlie patient
may die as suddenly as if a deadly poison had heeii lal^eti.
Luckily, most of the victims of this accident are not so ijuickiy
overwhelmed, and time is given for aticmjtt.-- at a re>cue. it
is not my intention to enter into a discussion of cxtra-titeiinc
gestation, its varieties, diagnosis, modes of ending, etc., hut
simply to introduce the .subject as it occurs in actual practice

202

TIFK ACUTK ABDOMKX

as a siirsical fiiuTgi'iu-y, so that yim may be abli' to n-cogiiise
and Huei'i'ssfull}' treat it.

Of instances of the mililer type w lien tlie luiMnorrhajie is not
excessive but recurs, tlie following recent case may be (|Uote>l :

M. ('.. afied 32 ; seoii in cousdltatioii with I)r. I>iil),'»'r, November 7,
1013, and ' .ansferrcd lo ilic Inispital for oitcratiou.

lU'V nicnslnia! ix'iioils hail Ixi'ii n-jriihir until th<' Ix'jiinning of
St'ptcnilicr : hctwccn iha' ila'.c and 1 he niiddlc of OcIoIxt tlicrf had
lu'cn no ))('riod. tin (»cIo1ht 14 a disidiaitfc cotuincnccd, which had
piTsisIt'd, of thin Mood-sia ncd lliiid. 'riicrc had Ix'cn sh;;ht pelvic
l)ain from time to lime for a month. A week hel'oie there had been
an exaeerlialion of this p.iin. and atrain on Novemlier 4, the pain
oausiuj; the patient to per>pire |irofii>ely. I'lie day before admission
the pain came on ai;ain and at midnijrht was very inti-nse, lastinjr for
throe hours. Tliis pain was in tlie pelvis and both irroins, and there was
great tenderness of the lower abdomen. She became very faint and
white-faced.

l)r. Bulfrer, who had been caHi'd in. diagnosed e-topic gestatio:. with
liiemorrliaire, and found an enlarged uterus with fulness in Jtouglas's
pouch. 'I'hei'e was also dist(Mision of the abdomen with some tendei-
noss in the lower ]>art. (In admission she was much the same, but iiad
a temperatuie of ilS-4 and a puist! of 128.

At the oi»eralion later in the day we fouiul scattered bh)od-clots over
the omentum, and Donghis's poucli was jiarlly tilled with bhu'k coagu-
lated blood. The left Fallopian tnlie was very congested and dilated,
esj)ecially near the limbrialeil extremity. Here there had been a
niptiu'e of till' tube and iin'morrhage was still jiroeeediiig. A piece of
amnion was f(>uii(l in the romoved clot. The otl.er side wa.s normal.
The tube and ovary were iemov<'d. The peritoneum was sutured
with catgut, the sheath of tlie rectus with silk, and tlie skin with
fishgut. Convalescence was interruiited by a troublesome attack of
celluliti.s.

Of the more severe cases of hivmorrhage I have selected one
of rupture of a sac situated in the wall of the uterus in which
symjitoms were very urgent and the state of the patient some-
w!iat desperate. It is a rare position for the sac to occupy, but
there is no means of ascertaining this before the abtlomcn is
opened, and the indications for operation are the same as
in examples of tlie much commoner rupture of a tubal
gestation.

A married woman, aged 35 years, was admitted -X- April 23, 1903.
Her history was as follows : — .'<he was treaied in a London hospital nine

yi-ars bcfmc fur ■■ l)L•lilouiti^ " after a eoufinemetit. She iiad had five
children. The younge.-,t was eighteen mouths old. The last menstrual

DISEASES or l-'KMALK (JKN Kl! \IIVK ORGANS I'o;;

jx'iiotl wa> ni\ W('tk> |Pirvii(ii>ly ; oin' >li(piil(l Ii.inc cnmo im iil"'iii ;v
wci'k liflnrc ailiui>sii>n. >lif liitd alway.-. ^iiiVcicil Imhii liut'onhd m, Imi
(lurintr tlic )>ust lew w<'ck< this had Im-iil woi-c I haii i vcr. Aliout a
inoiith ])rcviiiii.sly >li(' li";.'aii li> >iilli i Imiii allai'k-- <it \ uiiiil iii^ wliich
caiiu' oil oiM'cially allri- lonil, uhicii >hr wa-. mialilr lo iclaiii. 'I'licit'
was also soii'.f iiiilcliiiiic palii in llic aliiloincii. A Iciriiiiiilit ])ifvioiisly
slit' altcuilcd I he oiil [lal ii'Ul ilf|iaii iiiiMil ami \\a- Ircaiicl liir ^asliilis.
Till' ahiloiiiiiiai iii'.iu j^ol worse, and al J oClock mi ihrilay o! adtiiisvion
^hf had a vcvy seven' allaeU wiiicli doiililed hei u|> and later i-oiniil. lei y
pio^t rated liei. She vomited seveial tinier and lieiaiiie very eold, |>ale.
and collaii-ed. iiiuini: the atteiiioon ~lie tainted. >lie was liroiiuhl
to tlie liosjiit.il thirteen lioilis alter the on>el ol the severe jiaiii.
(Ml admission >lie wa^ l>!i;iiflii-d. eiiiaeialed, and in a --lalf ol eullap-e.
'J'lie alidoiiieii was held rather iii.:dly. and \va- generally tender.
es])ee'ally ill tlie lowei |iarl . in the leli iliac r.'L'ioii there was a
rounded elastic swelliiiL'. and there apiieaied to he lliiid ill the lower
|iait ot I he ahdoiiien. and to a le>^ e\leiil in the llaiiU-. 'I'lie |ilil>e was
Il'o and leelile. the respirations I't;. •.iyhinL'. and the temporal lire was
HT-' . .\t s p.m. a median inei^ion in the lower ahdomeii ahont 4 inches
in leii;;! h wa> maile. and the ilaik eoloiir ol the hlood could he seen
lielore the peritoneum Wa> ilici>ed. When Die alidoiiiinal cavil y wa-
opened there was all im medial e ;ru>h ot hlood mi\ed wil h c'oi>. and I he
hand Wa-! at once pa.^sed to the uterus and lulie^. 'riielell oiii-\\a~
eiilai'ired. and so was liroii.ulit to t he siiilaee. 'The en I a rue men I w a^ loimd.
however, to he due to a liydro->a!piii\, >o the uleriis and iinht iiil.c
were drawn up lor inspection. The toriner was iii|itured al ,i po:nt on
tlie I'uiidtls to I he inner side ol I he jilace where I he i ii;lil t uhe joined ii .
It was larj.'er than luninal ; the openiiii; was ahout I ', iiii-hi'> in leiiL;ih
and p;a<'ed 1 1 an^ver.-ely. i'lom il iheie proiinded .1 llutVy ma-> ol
delicalt' nior.s-hke tissue which tilled the oiHiiiii'.; and hiilj;ed oxer the
edyes. I'his wa-t evidently placental tis>ii<'. I'loiii this place there
was a constant oozini; ol lilood. 'I'lii^ t is>ue was removed wil ii a I'liiel t e
and tlie cavil y from wliiili it I'aiiie scraped oiil . 'i'lie openinj; was 1 hen
closed with a continnoiis ],eml>i'ri suiiire. This aiie>ied all hleedint;.
'I'lie left liihe wa> then removed. The inle-.tiiies aplieared pale, almost
bloodless, and eontraeted. 'I'lie iieritoiieal cavity \\ . ■ carefully cleansed
of dots and free hlood ''y saline irrigation ami }:eiiile sponi;'nu. alter
wliich the alidomcn was cloM'd. I'our [liiits of saliii" inlusion weie
injected into the left median hasilie \ein diiriiifr the operation with
evident henelit. Thejiatieiit .--!owl\ lecovered. < tli 1 he thii d day she
eomi>lained (d alidoininal distension and |iai:' in the epigastric n .^ioii due
to acute dilatation of the stomach, loi wliicn the >loniacli luhe was
em])loye<l. willi lavaije. Some distention ol the ahdomeii i mil iniieil lor
about three days, but the tem|ieralure rem.ained normal, and the pul.-e
about IiHi. Convalescence wa.s slow, and she did nol iea\e iiiilil
.liiue L".i.

!ti aiiothcf uaticnt the dia; nnsis. v.a.s rrti'ifi'fii lunisnaliy
dilHiult, tlii'iv Ijciiig a disciisi'd appt'iidix piist'iil, also Ixi aiisi'

iiii

f

It

204

THE A( [TK .\BI)(».MKN

of the lii>t()rv lit the illiio,-. niid Ihc ;il)>cii(c ot clnttiiii; in the
bloDil wliich had cscajM-d into the pcrilomiim.

A Wdinaii, Jiged 31 years. w:i.s jMliiiiitrd ^Apijl U, km 4. Tlitif wa-
LiKtoiy of iin'f,Milar peiiods, ami a wliili- (lix'liaiir"' "ii and otl' l>clwri>ri
tli<- i(fiio(l<. hut Kcrifial noxl licallli inilil .\|«iil S. Sin- was llini
si-izcd with iiiifiiial pain, wliicli was >.i l)ad lliai im I lie following; day
xlic was <)l;lijr,.(l to go to 1)0(1 ; it, inipidvid. bill rccmrfd severely oi;
the iL'th. It was must marked on tlie ri^'iii side, i unninj; up to tin iii;ht
tireast, :iiid all'ected the rijrht lei: so that it was veiy |iaiiihil to move.
This i)ain started witii the jieriod. which was a lortiiiKlit oveidiie.
\Vhen tile diseharire ceased the pain went, liii' came oil ai,'aiii wiieii tile
disehaij^e reliirnc'i Almost lailil iiiir. on admission slie appeared a pale,
aiianiii' woman. The ahdonien, >liuhtly distended and teiidei-, was
dillicult to examine salislaclorily, a> the patient held lierselt very
riu'idly. There ajipeared, however, to he more diilness in tiie ri;'li't
tiank than in the left, tjn vajiinal examination the iileiiis was normal,
freely inoval)le, and a little ret rovcrleil ; iliere was no liilni'ss in
Itoiiulas's i»oiich or abnormalily of tln^ iileriiie appenda;res. 'i'Ik;
toiiiriie was furred, lint the howi'ls wi re aclinj;-. The piii>e was II:.' and
the temiieiatnre WW f »ii the l.siii she was a^jiin -eized with ]iaili in
the riKhi iliac rej;ion. The vaj;inal di^charjie lecomihenced, liein^' of a
led colour. She felt very faint. The pain passed off dnriii}; the nif,'ht,
and on the next mornini; her temperalure was ](l(i-2 , and i>ii the
following evening lul". The history, character, and diiralioii of tin;
l)ain, with the rise of temperalure, made il very pro!. able that the
aiipemlix was diseased, whilst the account of the mensinial iiregulariiies
induced Dr. W, W. H. 'J'ate to suyuesi the po.»ibiliiy of an extrauterine
jrestalioii whii was leakiiii: into the peritoneum as a resiili of some
rupture of the ^.ic. On the l'SII h the <iperalion by tem))oiaiy displace-
ment of the rectus was ]ierformed. and a diseasi'd appendix removed
alter the application of the clamp. .\s free blood was juesent in tlie
jieritoiieum when it was oiieiied, and there was some in the p(dvis. the
ojiinion expressed by I)r. Tale was coutirmed. and rapid incision in tln^
median line low down ^Mve access to the ]ielvic oifiaiis. The right tube
was thick.'iied at one jiart, atid from the ostium abdomiuale luemonhag'e
was still ]M(iceediiig. This was ligatured and removed with the o\ary.
A tumour about tli(> size and shape of a jiigeon's egg was attached to
the left broad ligament. This was exci>ed, and iuo\ed to be an intra-
liganienlous cyst with papillomatous growth iiisidi' it. The apiiendix
was catarrhal, and siiiclured near its base. The right f'alloi ian tube
was enl.'irged and thiekoiied ; the iistiiim abdomiuale admitted a little
linger, and its niiicoiis membrane wa~ iiigo>c. 'i'he uterine end of the
tube tor a distance of 1 inch was normal ; beyond this It was dilated,
and contained a large clot which was attached to the uiiiie. and jiosierior
jiart of the interior. No lutus was loiiiid. The right ovary wa> cystic,
and contained a recent corjius liii(nm, besides several old ones. .V
pedniicul.'ited cyst co,iir,i,iii,g l-.l,„id-t ained iiuid was attached to the
right broad hga: • 't. The incisions in llie abdominal wall were closed

DISKASKS OF F^lvMALK OKXKRATIVK ORGANS 2m.-,

after tlie pelvis lia«l hvcn -poiit'*'"! uiul flusliod with warm «.iliii<« solution.
A work iat*'!- siio coiiiplaiiioil o| ; ,iiti jn tlio left sido of tlu- |>clvis, ;iti<l a
li;eriiatocel(.;,'i;iil,);il|y loriiKMJ and suppurated, boiiii,' opctiod />.!i nuiinum
about tiir'cweiiks after tho operation. She left hospital quite recovered
on Juiic 4.

This was. tlun, ,i case of tiil)al aWortioii. I lie i<»> of l)loo(l
cominii from tlic o|u-ii luoiitli of the fulx-. whilst the uniisiial
character of the jiaiii was cNpiaiiicd h\ tlic conilitioii of the
appendix. Tlicrc was no sudden seizure, a^< in the ca,sf of the
patient with intramural uestafion : hut the result wctujd have
heen fatal tiltimaf ely. and 1 have ipioled it as a contrast to the
former ( \ample. in all operations for haMiiorrlia<:e the uterine
appendap's should at once he hroutdit out of the wouud ,ind
• ■.xamiiied. \o .attempt to clear away hlood-clot must i)e
perinitte<i until the source of the haiuorrha<re is found and its
How arrested. Xo case is heyond >iirirical aid until actiiallv
dead. Kxamine hofli sido. toi' there may he a ru|»tured sac
in ' ich tul)e. As a temporary measure it is advisahle to a|)p!y
clamps to tiu' uterine end of the tuhc and to the hroad li<iamen\
hevond.

'I'he sudden onset of au appendi.x supptwation may simuhitc
the hinsiini:; of the sac of an cxtraaterine <resta(ion, if men-
strual irre<rul;irity and no markcrl rise of tcmi)eraturc are
present. A further sudden access of symptoms due to hm-sting
of theahsces.-, with colla|)>e. simulates a similar condition with
renewed ha'morrhauc.

■Some years iv^o 1 was called u))ou to ^'o into the country at night to
see a lady with au aeuie abdominal illiu-ss. The history was that len
days Lii'lore, when the period was a week overdue, she had had a .severe
attack ol abdominal pain, with lainlness and sickness, from which she
had gradually rallied. This had been regarded by her medical attendant
as iirobably due to the rupture of an extrauterine gestation, but as she
slowly imi>roved he did noi think that oj)erative interference was called
for. On the morning befoie 1 saw her she had been again suddenly
seized with a similar attack of abdominal pain, and bi^came c(,ilaiiseci.
The conditi(m u[ collap.se continued when 1 arrived, and was extreme.
The pulse was imi>erceptible, the temperature was subnormal, the ex-
tremities were cold, and the ]iatient restless. On the following morning
the condition was not improved, and, in fact, for four days she wan so
ill that it was not thought worth while to take her temperature. A.s a
result of careful tending she recovered, so that on the .seventh day after
I had lirst seen her it was possible to open a large collection of pus which

i:h

200

Tin-: ACITK AMDOMKA'

liad been known (o he present iu the lower iilnloineii for the weok, fnul
wliicli li:id not niiicli in(we;i>e(l iji size. There wiis no l;!oo<l-('lot in tliis,
iintl. :iliiiough I he Hi)|>enili\ was not tomid. it wat re;;:ir<le(l a^ the
|iriihiil)le eauMO o( the Mi|i|iiiration. iMirin^ tlie irradiial ehisini; of the
alis<es.s an extension o! it in the lell ol I lie uiiil>ihi-iis was (Especially sh)W
m recovering, ami ]>iis could lie expicsscd Iroin this part when eveiv-
where else the condition apjieaied t-al isfactory. In this re),'ion ailhesions
formed li^twcen coils of small intestine, and I operated for acute
intestinal obstructicin due to them later in the year. Still later in the
s.Tine year an attack of appendicitis made it advisabh- to remove the
appendix. .\ good recovery ensued.

iMrOUTANT Cll.Wtir.S ( OMIM.K ATlMi Tl Mot KS of TIIK rrivKTS

.\M> Tf-MoiHs or TIIK (>v.\ini;s.

W'i' will consider in the fiisl place snme ot the complieatioiis
aiisinii troiii eliaiige.s in ovariiin jifow tlis l)eeanse of tlieif ;.'feiiter
previilenci' :

(1) Torsion of j)e(licle causiiiji haMnorrlia|;e into the cyst,

acute inflaniination, suppuration, or gangrene of a
cyst.

(2) Rupture of the cyst, due to intracj'stic pressure, softening

of tile wall, or injury.
(1) In torsion of tlie pedicle the tumour lu'coiues rotated to
a varying extent, and according to the anunnit of obstruction
to the blood supply of the cyst will l)e the urgeacy of the
synipttJiiis. In all cases of sudden and complete torsion
■■ peritonism " i.s present ; sometimes thi' pain is so severe that
the patient completely collapses. A carefid examination at
this period of the illness will often show the j)reseiUH' of the
tumour either in the pelvis or in the lower al)doim'n. or the
patient may have heeu treated lor an al) lomiiial swelling which
had caused little or no discomfoit. and therefore the (luestion. of
opi'ration had bi'cn postponed, if it had been considered. If
the case is complicated by abdominal distension, then it may
be diilicult to lind the cause of the urgent symptoms, for the
rounded outline of the tumour will l)e obscured or completely
hidden. Kere there shotdd be no hesitation i»efore exploration
is carried out and the state of affairs adjusted, and in the more
acute ca.ses the i>atient docs not object, for she is sutfering so
much that she cannot h^ le the extent of her sufferings ; more-
ovtr, the relatives can sei' how ill she is.

DISEASES OF FEMALE OEXER \TTVE ORGANS 207

As thr- symptoms of "' p.Titoiiisin " pa>> (,(T tli.y arc npliur.l
by tliosi' of (a) liaMnorrliiigc, (/>) prritoiiitis or (c)'nlistni(tinn.
(«) Patients have hi-m known to die ipiickly ai tlic n>iilt
of intrapcritom'al Ini'morrliaj,'!', a> in th,. wvll-Unou n ca^'
(icsoribiMl l)y the late Sir Spciicrr Wells. In t|,is ili,. ha^n'or-
rhago hadbrcn pn-vimisjy into tlu-cy-t. w liidi iial l)nrst, ^i\in<i
rise to an enormous extravasation in flir peritonenni. In
nearly all of tlie torsions about wliicli we are sp,akin<; there is
Inemorrhafie into the tumour, but shoul.l IcakiiL'e take place
into the peritoneum, of a jiradu.il character, pos>il)ly inter-
mittent, the usual symptoms of lo,s of bio,. I w iiri,(.(.,,„ic
evident, witii an increase of dulness in the lou.r al) lomen and
Hanks.

The clinical appearance after luemorrhatie from a. ev-t « hie!)
has become more or less filled with blood as a result of toision
of the pedicle resembles very much thiil prcM ni d idter a
ruptured ectfipic gestation. The treatment i> >iriiil,ir ,'in>l thi>
urgency as gnat.

(It) The vomiting may continue .is the shock passes away, and
the character of it change. I'ain continues, with <.'reat tender-
ness in the lower abdomen. In addition there mav be disten-
sion, with constipation and retention of llatus. It i> |H.>sible
in tiiese cases that the obstruction is nal ,ind caused by the
pressure of the tumour, which, owins: to a .shortened pedicle
and increa.se in size, (an no longer accommodate itself to
ordinary intestinal movements, 'i'liis i>, however, not s,,
common as in those ca.ses where the const ij)at ion is incoinplete,
flatus is passed, the vonnting irregular, but rarel\- urgent.
Here the symptoms may be those of localixd jieritoneal
irritation with distension and a temperature. |>iilse. and
general condition indicative of .septic j)oisoning from some
intra-abdominal source.

(f) When a supj)urating cvst rujttures, well-mari<ed jjcri-
tonitis will devcloj) and prove fatal unless oj)erative procedure
is quickly resorted to inidcr favourable surroundings. 'I'lie
importance of early attention to a cyst wliich is causing pain
and a rise of temperature following on a sudden bout of pain
is therefore evident. Although after some attacks of this kind
it is common to find omental aiihesions at a subsequent opera-
tion, showing that recovery may follow, there is alwavs

flu

m

I

20H

Till-: ACl'T XRDOMKN

rink that iin it<ffitioti of flic rv>t liiM (>omini'iuH-il which will
tcrtninalc in uiin-jrciif. which no cflort itn the part of thi!
patient iir im-^licui ati'inlant can !<»cali-<('. It is very ilin-
lieart<'iiinj; to timi an aciife pi ritonitis in the late sta>,'e cau-<e(l
by ajjanurcniiu^ iy>t with twi-teil peilicle.wliicli in surnmniU'il
by lyinpii and stinkin-^ piirulmt Uuid, wliere operation has
been repeatedly postponed.

The hi>fory ot attacks ..f a painful character in the lower
ab lonien is uiven in a jiroportion ot the cases of cyst which
ultiniati'ly show torsion of the peilicl(\ b>it such attacks are
likely to be nii>interpr<ted and may be due to suppuration.
Va^^inal cxaniinatioii should not be lu-iilccted.

Si I'lTKATioN oi Cysts tKcuMi \uy to Im kction ikomtiif. Dicks-
TIVK In ACT. — A iiiaiiieil lady ol 41 was uudcr my euro iii IVItniary,
lOUT. Her previous liisti.ry was >.'<"»il . I>'it f"r four yoars slic had
coniplaiiird of ]>aiu in tin- lower al)doiiicii. c-iieiially oa llie left sidi-.
wlicu walkiiis: and dioiiii; tlie ealainciiia, wliiili weri', howfvrr, i|iiit«
rcj,'ular. fa .luly, I'.MXi, ^lic iiail au attack of diarrho-a. followiiic i>aiu
of jrnater sevtMity tliaii usual, across liic lower alidoineii. Voriiitiaj;
lasted for tlirce days and she was koiif in bed for a wwk. .Soinc swflliuK
was S!< = ;1 to iiave Ix-ou present on tlie left side. Three weeks afterwards
she lii another attack of pain and diarrhira and was kept in
bed io ten weeks. On this occasion the pain was on the rijjht
side, whiih was very tender. The temperature rost^ to 10l'2' and
remaiiied there for nearly tlio whole of the time. .><lie was evidently
very ill.

On examination the abdomen was normal jcenerally, but there was a
complaint of tenderness in tlie lower part to the risjlil of the rectus
nmsele At the position of (ireatest temierness a rounded swelling
could be felt. I'he uterus was rather fixed ; Tiothii\;; eUe abnormal was
discovered. At the opi-rat ioii a innltilocular ovarian tumour the size
of a cricket ball was found. It was ailherent to the side of the pelvis
and broad liiram.-nt, and had a short peiliele. The appendix was
adherent to it. as was also a coil of small intestine. The former was
removed, the small j:ut was sei)arated, a denuded place beinj; covered
in with a peritoJieal (lap from the surface of the cyst. I hiring its
removal tin- cyst emptied itself of veiy offensive pus and altered blood.
The smell of this was so very fiecal in character that the large intestine
in the pelvis was searched for a possible opening, but it was uninjured.
The main cyst was bouiul down by very lirm adhesions, which reipnrcd
very considerable force to separate them. The solid gauze packing wa"*
removed, and t he area iuvolvt-d cleansed with sterilised saline. Another
small cyst (not adherent) iht; size of an ogg was removed from the other
side. i)rainage. There was an' offensive discharge for a fortnight.
Tile wound cio.^cd in three weeks.

>j:r^imoujiB»jpg

DISKASKS OK FK.MALK (iKNKM \TI\ K OKCWS J(.i.

A Mippiirafiiiu inariaii cyst is not iiiiioiiiniouly fntind in
cani's where the appendix is lenmve.l after lueahM-l >uppiini-
tion. The spri-ici dt aii iipp.-iidix intlanmiutiun to a < yst may
pru.luce adhesions to the siirmiindinn P'""ts <.. exten-ive as ti.
reiiih'r its excision ipiite inipossililr

This w.iH s.Tii ill ii [mil, 'lit I fitly m ui I.. ,.,.« tiy lir. Ki-ilorli. of

St. All.iiiis. It WHS ii.T.'ssiii.v to iliiiiii th.' .yst. b.'CiiiiM' it^ lirtiily
a<ll).-f.nt walls were so tinu that liey s.-|.araf.'(l in ||iik.-s with tniicii
liii^ntorrhaKt'.

(!') Hiiptitre ut an ovarian cyst may take phice ipiitc earlv
after its tormalion, as iti a ca-*- l»ron;.'ht to me hy Dr. Wliiti'-
horni- ('(lie.

All inniiimicd lady liud coiisali,.,! Iiim for xoiiic sjiiilit syniptoriis of
illhcalth. and wlicu h'aviiin liis house ou lier way home was" s,.i/.,.<l with
a sharp pain in the ahdonicii. and l.iTaine so faint ilue she was lielp.-d
to a chiiiiist's. Here >he soon leroveriMl and oa the lollowiiiK dav was
apparently (piite well.

We thoujilit that the syinploins iniv'ht have r.een oiodiiced hv
niptiiro of a small ovarian <-y>t. .\ii exploration sjiowed that tins had
been the eause of her symptoms ; a nij. lined ovaiiaii vvM the size of a
largo egK wa» found on the Iclt .side and removed.

When tlie patient has u hirui r cyst the syin|»t()ms of rupture
may be more acute, whilst, on tlie other hand, in the ahsence
of sepsis, it may be impo.ssiblf to su\ wlieii the u.dl of th<'
cyst gives Avaj-.

J. B.. a married woman, ajred 0(», was admitted under the care of
IJr. Cuilingworth and transferred on April L'T, liH).'!. .she left May 17.

For twelve months .-he lia<l not iced increae in size of abdomen" hiil
rapid increase diuinjr two months. Th,. pain at liisi was raih.'r in<le.
finite, but more troublesome of late, drafininj; and tearing in character,
worse at nit;hl. Slic had been losing llesii lately. No vomiting, no
difficulty with micturition, 'there was a large swelling of irregular
outline in tlic lower al)domeii ; more on ihe left siih-. It ( xtended above
the level of the umbilicus and to the costal margins laterally. 'Jhere
wan marked vermicular movements of the intotine,- in front of'the upper
part of the .swelling. Theiv was some tenderness over the right side of
the swelling. I'hwt nation could not be obtained. There wa.s^resonance
on percussion over the greater part of tlit^ swelling, the only area of
dulnoss being iiniiiediately above the pubic ramus on the left side,
rtenrs small, and movable independenily of ihe swelling.

When the peritoneum was opened on" April 28 a lai"ge amount of
yellow jelly-like material (like lirand's essence) exuded. When tliis
liaJ been wa.-iitd a\va\ a peduiuiiiaied ovarian adi'noma llio size ol a

A.A, „

.„■■-<"■,,

210

IIIK .\( I'lK AlJDnMKN

foKthall wat riiiioviil lioiii (he nulii ^kU-. In ihi- ili<if w.t^ a l.iii;<"

rii|Miin' Willi ■vnltil civ;!-.. .MtLnllv nl ■.oiii.' iUi\n i. In ili<' '>-'

with wlii.h ll i» iiiiiiiiiiiUMalf.l u,»^ vimhI >.II..w |4|I>. ami ih" wall WiW»
liiii'il with ail.iK.iiiulin-oiiliiiliilit' ■.iinilaf ji'lly, '•ill n l«w "I ili''*'' wric
rnlfili.'il. '111.' i-vsliiliiik WiW Jiol iiillii'irlii. 'I'lir U'litl iU"M-. innlciiul
Wiv« (lilliiult to Wit-til away, iiml !■ H I li<' '•nilarr <il lln< iiil.'»lluo ijuito
wiM.lly ill aiiiMaiancr. nili.r »li iiclnn-. wiir uniiiial. ami t lif woiiud
wan rloi'i'tl.

Jf till' patiiiit \\a> Kiinwii to lia\.' Iiail a tiiiiioiir llinr will
|)roi»iil)ly lif ii cliaiip- in il> iiiitlinc ami iviiUiui-s «.t trir lluiil
wliiili \\.ir pivvinii-ly waiiliiiL'. It 111'' n|Miii!m is coinpani-
tivrly Miiall ami the liaUa;;f >I()W. mt.v littli' uiii.ii.y may Im-
nIiow II at liist . a MiiiM \N hat rapid iiiciia>c in >i/.i' oi the alxloiutii
l.ciiit; llif inn-l iviiltnt tliaii^ii'. To llii> \mII '"• aiMcil a dilli-
iiilty in lyin<i \\itli a luw pillow ..r in iimvinii ahuiit, and i,
^wfllinji oi' the li'^is. Kxaminatinn may ^ivc tlir |.liy>ical -i^ns
nt a very laryc iy>(, fur the tluid, luiny: nl lii-li ^jxcilir liravily,
i((inpn'»rs till- intcstints aiiain>t the >pini' ; i< -niiaiu'c i- tmind
over lilt; colun on both >idts and diilnc» « iMwlicrf.

K\(K.-<SIVr. AllhoMISVI, |tl^li;N«lnN 111 I, Ml l!l I'll l!i;i. OVAUIAN
('\>i (IkmUmI >iiciT>-liilly iiiuliT adwiM' (•ii«-iiiii-lau<c<). — Soiiif yruis
ayo 1 wa^ a^k.il l-y my IikiuI l»r. A. .1. >..iiili.y, ol (olulMODk. i" m'." a
putiriil w III him in a villaji.' not far lioiii l^i.nilini who rifu-f«l lo have
hiT hoiiif ami ;,'«> to a lifi.>i>ilal. She \va>> a .silicic woman i»l ."Ki who hail
iioliifil an alidomiual cularjifiiifiil lor mhiic inoul lis w liirli had ImTcaxil
rallu riapiilly for a l.w wc.k>, >o that hr l-ari'tl ilif caMt* would iiavi; a
fatal fudiiij,' if he coiilil not indiicr a siii>;foii lo i.'o and ii-lievt) luT. Alter
talkinj: Ihi' taMj ov«r it was aiiaiiuvd thai w.> slK.uld iiicct at tlif liouso
[iifiiarcd lo do ovariotomy it llic diajiiio^.is whidi . ,'['>■■ ■ 'm"*t-
lirohahlr inovcd corii'i-t. Mr. Civrter IJraim;, the .■mimni alia-lliftist,
kindly amtcd to airompaiiy inc. On arrival we found tlm i>aiitiil m
tlm fioiil room of a row of i'otia;t<'s, the window of whirh ('aim' <iuitt'
up to the iiavcniciit. The |)ali*'Ut, who was jrieatly distended, had m»iii'<
dy>l>n(i'a, and eonsiderable iidema of hotli lower extremities wliieh
extended on lo the alidomina! wall. 'I'lie >iiiroiimliu^'s were most un-
favouialde for oi>ciation. liiere heinv' a limit eil Mi|i|>ly "' Hneii, ol soap,
aud only a low tal.U' thai would hear her weifxhl. The only other
person in the, house was a woman of the woikin;.' elass whose ae<iuaint-
auee with modem ideas of eleaiiliuess appeared very limited. 'J'ho
supply of hoiled water was very inadeiiuale, hut we kept thia assistant
euKaHed iu prepariuj; more.

The ahdoincn was very lar^'e aud of rounded outliue, dull all over
except iufi iu the flanks. A lluid ihrill was felt ihrouirhoiit.

.'^lie did not like lyiii^' on hi^r haek, and when she was under tho
aiiaslhetie it was necessary lor her to he held in po>iliou whilst tho

!— I^KHPIHW

rUSKASKS OF KKMAf.K r.KXK|{.\TIVK OKCANS ^.n

iruifiiiii WiM iiiatlr. Muiy |iiii(. ..i HiimI ».i.- i.,k,ii ««.»>. .m.l an

..Viuiull MlllH.III. on.' of III,. |,,,;;,| .X,!, ..I Hhlrli |,.„l |,||.lll|..|. W.IH

irii.ovr.l iK.ni llic Irll -Ml... Anolli.T an.l Mn.ill.i mull ilnnihir ui"wili
w,iH ;.,iii„l m 111.' |...|m>. ...Hi. i.ni i.. il,.' ,,^1,1 ..,|,. ;,,.,| ,„„,,.,„., n^,„vt

"I 111.' ul.iti., ; to fi...' till, |,.,|iiii..,l ||„. .,,,1 „| »l,,,i,i{ M'i,h..iv '11,0
iiit.'.iiii.' i.ni iiii.'.l tl.iii.n.'.l iiuMin-l ili.' [.ci,.,,..! wall ..I ih.' ,»I..|.,mi.'ii,
an.l Ih.. .ilMliiiiiiiial w;ill in lioni „','ni. 1' x.i\ i|,i,k. h.aw. ,.i,<l all..-
i:.llnT I.H» laiu.-. Th.' i.'iiiainiiiK limit .\a> .j.-.n. .1 .i«a\ uiil, ^aiiz.'

-wal'H ami tin; infi-i<.|. .'I. .„.,!. sh,- ii,,,,!.- a u I n.'i.v.i \ . |i|

^ '"■> »f"V" "'<"*t valiialiN' hvlp. an.l lln..iii.|, |,„ ,l,'v..ii..ii' |„ i|„.

w*"" ' '•"' •••'''• wiilioiil any .■..nM.l.iali.iii .il hi, ,,wn ini.iv«i, (I,..

' '•'■'• W'niin wa> |.i.'M'i\,..l, |,„ ,h.' ha.l nia.t.' ii|. lur iiiin.rihul

'•he Wiiiilit tlii' al liDitii' : "

'llif an .vliiili i* I. it ill 111,' |Miii um in mi, li .a^c. 1,1, ly

t.iU.' tliivc to tnlif \\t'ck> lii'l.iiv il I, ;il,^,,rlM'(|. a^ \\,i> -Iiu'.mi
III a caM- wli.'iv tliciv w.iv lidiiial -h ~ in il,,. ji,,,,,-. h|,|,-|,
liail hiiu (i\('i(li-^tciulc(l hcluic (i|!.iali(iii.'

Occasionally tlic tvniaiiiin;.' tiiiiioiir cm he inaJi t.. trav.'l
llolll side to >i«lc ill the tllii.l, it tin- pedicle i^ ,,t a.i.'.|iiafe
Iciiutli. Ai^aiii, an iiileete.l ('\-t may ]„ com.' adiieivnt to th.'
Ixmi'l and dischafne it> eoiitc nls into it. Jn tlii> way a patnnt
may |iro;;re.-. uitli fair coinloii (or a loii-_' tiiiii'. c.\c..|,iiii._r tor
• urasional inllaimnatoiy attack^ j,. i|h. ^■y.^ ;,,„i ,|„. incicaM' in
size of the re-t o| tile tlllllolir.

Tiieiv are two conditions allcciiim snlj|)eritoiical uterine
fiiiroid which may i.'ive ri-e to an acute alKlomen, the lirst is
the twistilli; of the |iedic!e, the second is acute liecro>i>. Jiotii
are rare compared with the fre((iiency with wiiich the complica-
tions of ovarian tiiiiioins ol.trude themselves on on,- notice.

TuHsiuN 01 iiih l'i.i.ui.i. 01 A M i;i'|.i:ii.,m:\i. ;,i;K,ai. 01 imk
I illll.s i:i;si;Miti.iN,i ,\,iii, .\|'|'i:m.|, 1 1 is,- .\ii iimnaiii.'.l woman.
:i;.'('il 40, wa.s ailiiiil l.'d loi ■ aiiii.'iiili.itis '• on Ociobcr 3(1 ami l.'lt
.NoM'iiil.cr ;;i. im.i.

>o far as ihc iialii'iit kn.w, slii- ha.l aiwav. h.-.n w.-lj. wilh llic .'Vt'eji.
lion ol liouhl.'soim' .'on>ti|ialion. iinlil (i.ioh.i L'li. .md her jh rioil, had
liii'U normal.

<in that day she was sii.ld.nly atla.'k.-d willi |.aiii lu ih.' Iow.t
.il.duiii.'n, nol inoiv on,' -i,!,' ihau ||„. oi|„.,-. 11,1^ i,.,,,, ,.„ntiuii..il ail
day, ami in the evening; .she imiicil ihat ili.- al.dom.n was swoll.u.
'I'lif pain was wois.' alter loo.l, hiii .she di.l noi vomii ; it was ai.si.
iluTfu-st'd hy iiii.'luriii,.ii, and I her.! was some dillieiilly at the eom-
nit'nccm.'ut of tli.i aci.

t-tu adiiiis,ioii the pain was .hii'ily on the hli >id.', Lui ea^cr. Later

sfu Iraiis. Ml'I.

I.Miid.

1' J

212

THE Afl'TK .\BDOMf:N

i

ill ilid ihiy ihcio wii.-; distiucl l.iiil.-nu'ss on the rij;lii sido. witli some
<listflisi(m ol tlu' liiwcr ;il>(l..iiicii. iiiul an ill-tlcliucd swrlliiif.' to the
lijriil ..1 Ihr uiidilU' liiif. 'I'hf Iciiiix-ialmv was liKid and \niU- 10«.
Vafriiial fxaiiiiuatioii was lu'fjalivc.

Shf was kcjil ill Ix'd. and llio distfii>i(>u (liiiiiiiishi'd so lliat a swclliiit:
in tilt' ti«lil lowiT alidoiinu roiild lie dtliiicd. Its uiipcr boundary was
iMund.'draiid iIk' wiiolc >w.-llinf,' tav.' tlic iiniiros*.:ioii that it waw tlie
-izf ot an ostiidi viij: and arox' tiom tli.' ix'ivis, l)ut it was not possible
to a-<'filaui wiifliur tbcr.- was an.v llurluation in it or not. As tho
inlianiinalorv svnii>loiiis were (luiflmj; (b>wn, op.Matioii was i)oslpoiied
until Nov.Mn'bfi" 7. 'I'be inci.Mon was made to the right ot tho middle
line and the reel us di>plaeed outwards. The tumour was a sub-
peritoneal libroid, firowiuj; Irom the iijihl posterior a.^"''-! of the
fundus, the size of an oiailfre, the iiediele of wliieh was twisted. Tins
wa^ ehimited and th<' libroid <'ut away. The left ovary was eystie, s<,
this and the tube were removed with the uterus by supra-vafrinal
amputation. The uterus preseiiL-d many libroids of difleront sizes in
and about tlie body, but the one winch ha<l b.'eii removed was the
iar"-est. This was i'ntlamed. and on .section showed extensive lisemor-
rlia^pe into its sub.-tance. The appendix was lon^' and contained concre-
tions, so it was exci>ed ; it had not been recently inflaincd. Recovery
was uneveiUfnl.

After the tumour was delinitely outlined on lessening of the intestinal
distension, she said that she had noticed swelling there before the
present attack. There had been no meiiorrhagia.

Wlu'ii the rotation lias licfii inoiv gradual in its proszrcs.s we
may iind adlu'fions to tlu' .surrouiiding parts. wlii<li in their
turn as tlioy t)ccoini> oroaniscd may proilticc obstruttion ot

th(> li<>\vei>.

In li)U3 Dr. l-'airhairn ' made a valuabk' oontribution to
the study of oiu' of tlic varieties of necrotic change, the .so-
called •■ necrobiosis "" in tibro-myomata of tiie uteru.s. Altliough
this is well recognised amongst gyna'cologists it is not often
met witli. nor does it necessarily demand inunediate operation.
Still, tlu'fe are eases in w hicii urgent .symptoms ari.se. commenc-
in" with an attack of acute pain in thv lower abdomen. Tain
was im'sent in Hi out ol -':'. eases which Dr. Fairbairn collected,
and in all it was the reason for the ])atients seeUing advice.

The following is a good example of the more acute process : —

A married woman, who was four and a lialf months pregnant, was
admitted in I'Ju:!. Five days before >lie had been suddtnly sei -.-d with
an attack of violent pain in the low.r abdomen, and the , ,iin and
vomiting continued when she came m. For four days a swelling had

' Journal of Ohst,trict,iH<l (i yiKiCvioijij. \W.\.

m\

- i.' , :'. .--:;!£-*

Ar.j^Stt'c'SV;,..

,^TJ^j^jm..^:i^w -i:^nK?^:.

DISEASES OF FEMALE GENERATIVE ORGANS 21 .{

Iicpn noticwl. 'Vhr alxloiiifii wii^ ciiIarL'"'"!, |in <cniiiij: twi> tuiiidiirs
lising from fli(> iiclvis. 'I'li<; <iu<- on the iii.'lii w.i- the .--I'f nl iivn li-is :
that on tlif It'll was tlic i)ici.'iiaiLt uifiiis. 'I'lie ioiii)i(iai iin- wa> it'.i
ami piil>(' I 18.

At the ojtcraiion a iK'cidiic lilnoiil wa- li'iiiovfil fvoiu tlir aiiti-iioi-
and ri;;lit asjuM't of tlic iitciiis. I'l],. atlucluutut of lliis niiin.iir lo llic
iitcnis was family scparatcil wiifi tli.- liugi'i-, hut it wa- (lillicnlt id stop
tlic IdiM'diiifr fioiii llio raw >iiifacr left, as the iissiii's wfic v.tv xiIi ami
suluri-s easily pulled out. Pressure willi sjumnes >(iaked in Ijoi ^,•ll^le

soliilion apiieared to answer iii iVeeiively. Tlie woimd v. a- elu-i il.

and she recovered without . i, .n; .^. .,■.■. airiiou-li a low lemp.iai luv and
quiek i)idse eotitiuiied for s- siie days.

The altaehiiieiit of the I im t ki ili.- r -lus. wliieli wa- iMi>lied Ik
the left, was ill tills iiistaiiiM • .■ y.sli'j.iil aiu it, wa>* not pii>sil)le to liriiii:
flaps eoiiipletely ov<'r tlie ra. t •. > 11, e tissue- aiouixl the ;iilach-

inenf appeared to have uiideriroiie iiitlaininalory Mifleiiiuir and would
hold neither suturos nor liiratures.

Similar cases an' rcfcifcil \'< liy Dr. l-'iuihairii in liis
papiT. iiolalily iIkisc utvler the cai-r n<i Khmi-Siittnii. Di.rati.
aitd Mackfiiradt. Uiainl-Siiltoii lias |i(iititcil (Hif tin- liahiiitv
to mistaUc these cases for axial fotatioii of an ovai'iaii e\>t.
Ill either case o|ieratioii woiiM he required, ami thri-cfdre t!ie
mistake would not iiave any -i-riotis ciuixiniencts. .Mo>t of
the patients were })remiant and there was no histor\ of
menorrhauia.

S^

pif

.^..ttlk^

...J^

^^

Jo.'. .

1

llr-

IWUT V

OTHKR (Al'SKS OF I'llK M'VTV. AI'.DOMFA

Ar inlcrviil- one meets with ea-e^ sliowiiii; acute alxloiiiinal
>viii|)t()iii-;. such tiiat a diaiziio-is of mie of the disea-es ali'e.uly
(h'^erihed may he wioii^'ly arrived at : yet on Dpeiiiiiii the
abdomen the ajipeiidix. iiite-t iiies. and stomaeii (h) not sliow
any of the expeeted lesion>. thefe is no o})stniet ion of the
bowels, and search must lie made for other possible eaii-es of
the sym|)tom-. Acute pancreatitis or acute cholecystitis ai'e
perhaps the nio-t liUely of these, ^'ery occasionally an acute
dilatation of the stomach may have <.'iveti rise to the symptoms.

,\( ITK H t.MOIiHll.MJK l'.\N( |{I-:.\T1TIS.

Tn this disease tlie onset is >udden and associate<l with severe
alidominal pain, located usually in the tiiijier abdominal and
umbilical rciiions. 'I'lu' sij^ns often sui;<_rest acute intestinal
obstruction ; at other times |)eiforation of an nicer of the stomach
or duodeiuim. or acute bacteri 1 invasion ot the ))eritoneum.
such as that by the streptococcus, may he suspect<'d. .\
historv su<;uestinir pre\ious inllammation of the i.'all bladder oi'
ducts i> occasionally obtained. The follow inji case is that of a
patient who I'ecovered after operation >-

A widow. iiKt'il .')7. was sent to my care liy I>r. <i. Drchiii'i Scott, ot
Hrixton. tor ati aciilc alxloiniiial iliii<>s. oii I'clinuuy 2:i. Iltnil. .\t
6 o'clock on I'clMiiaiy L'^ she coiiiiihiincd ot meal iiain in tlic alxloincn.
She said that it hciian on the rieht side and >)iiead rajiidly to the h'fl.
and also e\tended tiiuvards to tlie rijiht costal laaruin. She was siiU
at the same time, and eoiild keeji notliin^r down siilise(|iienlly. llei
liowels had acted iiatinally the ))revioiis niorTiinjr.

'iheie was no history ol liiliary colic or ol iniiiry. and she had lieen
(pnte well until this illness. She was a well-nonnsjied woman, who
.^till complained (at 0 p.m. on I'eliriiary 23) ol alxlominal iiain. 'I'lii-
wa.s now geueral all over tlio abdomen. She looked ill, had a pulso ol
IIU. and a temperature of lOP. 'I'lie abdomen wa.s distended, generally

m rii I

'Skf^^

OTHER (ArSKS OV THK .\( ["IK Al'.DoMKX 21.-,

Iiarrl to tlio (diicli. ;mil vi'iy ti'iidiT. but not ^picially -i. in 'hi' iliac
li)-,-;l. Oil ])crciissii(U llicic w;i-i piitcliy (liiliif><. Ii.,i|j in t,i.iil ami nti
t}ie lut<Tal as|(ccls r)l the aliddnii'ii. l«ut ikiI in tlii' Hanks. \,, alpiioriii.il
swolliiij.' ('oiilil lie Ifil. ImH tli(> wall ol th.' alHlom.Mi, uliii'li ua- lal. was
also (listcndcd ami ri'>i>iant. Ili'i- limbic was dry and liou.ls nut
actinjr. At tin' i.'ciatidn. wliidi was pi'i lunmd almiii ini-nt v-toiir
liinirs after tlic In mnini;- ol syiii|iluin-. an inrision wa> made on tin-
rif^lit side tliioiii;li llie iiclns iim-ilr. Winn the ](c. it.imuin uas
o|ifn<d a irood <lfal nt lilood-slaimd tliiid f-(a|H'd. 'I'lnic was no
lyniidi on tlio ncriton'uni. Init tlic onifntinii .ii)|)(ai-(d sonifwliat thirk
and intiltratfd, wliiKi in more than onf s])ot llnir «as ,at mcicviv.
'I'lic ](ancr.'as apitcaicd liardcr than u-ual, and rulariiid. Th. i;all-
bladdcr was normal ; no stone eonld he telt eiiher in ji ,,i- in the hiliaiv
na^sa^es. Tlit^ small intestine on the ni;ht side was disiende<l. The
peritonPUlinvas washed (Hit with mirmal saline solnt ion and iheimi-ion
was dosed. .She was relieved l.y the operation, hnt on the lollowini:
evening her temiierat nre rose auain to KMi^ and )mlse to Kit!, so the
incision was reopi^ned. the jiresenee of fat neerosis conlnineii. more
lliiid evacuated and a diainai;e tulie jMit in. 'I"he followini; dav I'am-
midire's test (■ was re|ioried as jio^itive. The jiatient was ver-<- ill tor
some days, ami at one lime appeared very weak. Hushed ami despondent.
Drainage was continned nnlil M.iiudi In. alti^r which slie gradnallv
im), roved. It is not neees>ary to givi' any further details. She left
hospital on .\]iril 2(>. liavini: quite recovered.

A more iiciitc case', hm one which caiiic iirnici' t teat iiicnt
ciL'lit hours after the (•(pumiciicciiiciit of >vm|)to!ns, wa- that of

li. L.. .med .•{!•; admitteil .lannary L'.^i and left March ;!. I'.ll 1. l'„v
abo\it a fortnight he liad had a feeling of slight illness, hnt never any
abdominal ])ain or special synqdoms. At 15 p.m. on the day <>{ acl-
mission lie liad gom' to lied to ii'st. when he was seized with violent iiain
in the ejiigastrinm. 'I' ■ continni'd and lie vomited till he came up
live liours later. Jle '■■;;. strongly-built man who looked very ill.

had a resjiirafion (d L'. f 72. and temiierat ure !i7 . The abdonn'ii

moved very badly witi ' , ..atioii and was rigid all over with aieas of
well-m. irked dulness in tiie flanks, in ilie left iliac fossa, and in the middle
litn-of the umbilii'al region. There was general temlerui'ss and rigiilitv,
the tenderness being most marked over the >tomach region.

The man was sent in for supiiosed jierforation of a gastric ulcer, but
in discussing the case befoic operation we came to the conclusion that
he had acute piincreat itis. About eight liours alter the onset of the
pain an incision was made in the epigastric r(>gion to the left of tho
middle line, tlio rectus sheath opeucil and the inuside displaced to the
left. As soon as the peritoneum was ojiened there issued a (juaiitity of
thill watery blood. More of this fluid was found hi the flanks and iliac
fossa;, and in the lesser sac of the iieritoneum.

The peritoneum over the ](ancreas was softened and felt rather
shreddy, and it was possible to expose tlio gland by using a pair of

t"

r /.,'.'

!#*• 'M-^ s-

w

2I»)

THE ACUTE \BD0MF:X

,4,

i

dressing fonn'ps. It folt hard, was pulargcd and somowliat lobular.
A tulu' was passed down to the pland and jjaeked off troin the peri-
toneum : it was in coutaet with the yland at its lower end, and in
i()usei|neni'e ol the size of the jiatient was ol unusual lenjjtli. A snpra-
|nitii( ])uuetiiie was also made and the iieritoneuiu tlushed with saline
solution (temjM lature 1 1" ). There was a s\ispicion of fat necrosis
alioiit the ducxlenuni. but nothini; definite. Fatty material eain( away
in tht^ irrigatin;,' fluid. 'I'ulyes were left in both wounds.

Dr. Dudgeon rei)orted : " .lanuary IJo. 1'J14 Cainmidgc's reaction
test C after fermentation. Negative."

For tlic Jiist live days there was free drainage of serous fluid from the
up])er wound, but after that a thiek purulent discharge from both
wounds. I'or some days he conii)laiued of a great deal of epigastric
])ain, and there was fever with a ]>ulse of 1(M(. Hut his ex])ression was
g lod .md the strength of tlie jndse satisfactory. 'I'ho drainage tube
w's removed on .March 4. The discharge graduallj' ceased, but the
wounds were slow in liealing.

Acute pancreatitis is most commonly seen in adults, especially
males of wiore than 40 years of age. well -nourished and even
fat ; possildy the patient is a free liver wlio has been in good
health until seized with a sudden attack of severe abdominal
pain and tiigeiit vomiting. On examination tlu alKlomen has
been more resistant generally than it should have been, but not
rigid. The epigastrium has been most tender. l)ut there las
been a diffused su])crfieial tenderness. es])ecialiy on unexpected
light ])alpation. in other parts. The general resonance over
the abdomen has been rather patchy in character, whilst the
movements during respiration have been good. In all the
pulse has been rapid, the temj)erature elevated. 101° to 103° ;
there has been anxiety, and not infrecjuently a flushed face.

If the abdomen is opened within twenty-four hours the
amount of blood-stained fluid will usually be small, but some-
times may be in sufficient ainoinit tt) cause dulness in the
flanks, and may be supposed to have come from the wound ;
again, at this stage, it may be difficult to find any points of fat
necro.-is. In any case, in the adult when- nothing is found in
the more usual ])laccs to accoinit for acute abdominal symptoms
search shoidd be made for thc^e patches, which are yellowish -
white in colour, and of small size (Fig. 30). If nothing is
di.scovered to account for the .state of the ))atient. then it may
be well to put in a drainage tube for a few hours at all events,
for a discharge of a red colour will soon come away, odourless at
first, but Later, and when in Larger quantity, having a peculiar

j^ .^^m.

OTHEf{ CAUSES OF THK .\( I'TK .\Bl;i)MEN i'l7

mawki>h snicll. ■vvliicli, -.<> far a< T know, rcscnililo iiolliin!.' cIm-.
TIktc may bo no evident ^wellini: of liie ]ianriv;i-. .M;iii\- ca-e-
will .Illy be diai^iioved wlicn tlie opfncd iM-iitniicnm -li(i\\~ the
pre-eiice of spots of f;i! uecio>i> in the (inientinii. lli.- eMiii.c .if

odourless })l()o<l-taine(i ijnid
This fluid may. however, be
thoui.'lit to have run into
the deeper part> from a cut
vessel in the wound, unless
it appears tiaky. and the
operator is ])repare(l to
find it.

The previous history may
be of the greatest imjioit -
anee. ])ointing to the
pre.s(MU'e of gall ->t ones or
uk'er of the stomach or duo
denum. Sonu'times there is
a history of an acute abdo-
minal illness of doul)tful
f'lusation.

The principal abdominal
catastrophes -with which
this disease is liable to l)e
confused are — the ))erfora-
tion of gastric and (hm-
denal ulcers : in the male
the resemblance to the latter
is very close, if there ha-
been a history of fornu'r
attacks of pain and there is
much fluid in the jieritoneum
M-itliin a few hours after tin-
acute onset. If the vomit inf.

avnig Inst ;ittracte(! altmtion.

"n;. .'i(t. I'iit Xirin~i». t'lnin a S[ir{ iini'ii
in tlic J^.^:ll CmH.'l''' I'l' Surpi'iis
Mii^finu : ■J.il. 1, < Hii.rnl ratliolo^'y.

continues and there is a ri>ing

temjterature with patcliy (Uilness and general hypera"~tlie-ia of
the abdomen in a stout adult with previoin godd health.
tluTe is less (litilieulty. but even then a >niall perforation
might mislead the inexperienced, although there is a great
difFerenee in tlie appearance of the two patients aiul in the
.'5tat(> of tlie lower abdomen.

>18

THK ACUTE ABDOMKX

iKiij

Mil

fn iiitotiiiiil okstruclioii liiyii up iii the small iutcstiiie there
is tlie saTiic kind of initial ])eritoiiism. Tlu> syniptoins arc
severe, voinitini,' tnnihlesoine. and e()ii>tii)ati<)ii marked.
'I'lieie is nil distension at lir^t and hut little peristaltie move-
ment vi^il)l(•. it the patient is a female over middle life,
without any lu>tory of >iall-stone colic, the diagnosis may l)e
dillieull in the lirst few hours after onset. })ut as tinu' jiassc s
the symjitoms in this foini of obstruction chanjic. the jiain is
more detiiiitely of a |)aro.\ysniid cliaracter. the site of the chief
pain hecomes more umhilical. uiiiUt |HiislaMs is .seen. Tn
thin people a lump may lie felt which is lU'ithcr in tiu' |)ositioii
of the <_'all hiadder nor of the pancrea-. .l)i>ten>ion eonu's on
in the later >taLn-- as the irallstone approaciu's tlu' ileo-ca'cal
valve and the symjitoms show a (•on>ideral)le change as the
stoiu' is pa-.-ed idonJ,^ If the patient gives a history of opera-
tion for an alidominal condition, or has l-.ad an illness which
might indicate the po>sil)ility of internal adhesions, this must
he fidly discus>ed.

1'he presence of the tumour in cases of acute distension of
the gall-hladder. with its roimded outline, aiul the localisatiou
of the paiji and ten(lernes> to the parts under the right ui)])er
rectus, with the riszidity of that muscle, will suttice to indicate
the nature of the mischief. There luay l)e no jaundice. A
tumour is rarely felt in acute lia'inorrh.igic })ancreatltis.

In a case >een at a later stage it may Ik- very difticult to
saythat theillnos isnot due to an attack of acute ajipendicit is.
This is so in ho>pital work more than in ])rivate. To gi\ ;> an
c.xampic :

A (li>iif worn;'!!, bj- no iiiciuis Jutcliigi'nt, ovit "id Y(>avs of igc. wiio
;ili))lii'(l. with pain aflrr time or lour days' illness; a (list ciidfd abdomen,
witii diuiicss in ilic Hanks and ■ucncral tcndornfss. Kapid pulse,
loinperaiure Km , and oontinned voinitinp. \\'it]i these symptoms and
si;;ns, an inaliiiity to say wliere tlie jiain began, and no liistory of
Jiii-vious illness.

Still, even in such a <'as(. as this, that of a woman aihnitted in Decem-
ber. llll.'J. tliere were signs which jiointed to the ajtpendix as the origin
of file trouble

The muscular wall se(>med moic rigid in the right lower abdomen,
the dulne.«s was more evident in fin- right Hank and iliac fossa, wliilst
tlie acut<' tenderness, indicative of sjireading peritonitis, was most
marked oti the left. Tlie epiuastric region was witliotit rigidity or
special tenderness.

OTrrER c.M'SEs OF Tin-: mvtk akdomkn' -i-,;

Sho liail .n Konoial peritonitis s.>,.,„i.l.iiy to a (;niii:ioiious aj.-x.Tidix
and .lifd in the following month, wlim ronvak'sccnt alter tlie ..i.eration.
from ha-morrliai;!' from a gastric iilcir.

These [.iitieiits are not uood >iil)j,.,t >- for an alM|,.iiiii:a|
operation, ami I helieve you ^ill u,.t bcit.r ivsiilt> in moM
eases from siiMi)lc itiei^ion wit), the in^..||i,.n of a- lai<:e dr.iinai^e
tiilx' down to tlic iMiicica- will: -aii/.e [lackinj:. lli.in froin'a
more elahorate operation. ,Mo~l of them will not >tan(l a
proh.nir,.,! maiiipidation.with the larncr amount of ana-thetie ;
it I- pos>d>le. however, to do mneh more if the patient i- in fair
eoiiditioii and not too fat. 'i'he ide.il operation i> to ineiM' the
tisMies over the |(,inerea-. Mith chie regard to the ihict and
mam ve--sei>,and eMahli>h a ihrict route for drainage, packiiiir
otf the 1iil)e with uaii/.e ; iHifoit nnalely the action of the
secretion from the^land. if much cMapes. on the ti-siies with
whicli it comes in contact i- very dotnicf ive. and if the liow
is profuse you will find it diliicult to pre\cnt actual di^'c-lion
(it i)arts.

yiiv. Barker' suL^L'e>ts that when tlu' operator tinds in ,ui
eaily case that the acute proce-- i> mainly or eni irelv ret ro-
periloiieal, it will l)e aivisahle to drain the atTccted aiea hy a
lafH;e tube pass,.,| from the fh nk alouL' a track partly m.'ide
hy the foicfin'jcr. in thi- way he may elo^e the ant.aior
wound without draiiiau'c, and avoid po-sihlc complica,tion>
from adhesion^ in later life.

If the condition of the patient permits the time re(|uiifd for
till' removal of any ,<iall-st(,ne.s that may l)e di~covereil. they
should l)c removed and the jzall likidder drained. Should a
stone he pre~.ent ill the common duct, it should he extracted, a
drainage tube pa>sed down to the openinji. and i>olated hv
gau/.e. Sir Merkelcy .Moynihan recommends that ■icee» to the
l)ancreas -hould he ohtained hy making an oixMiiiiLT throULdi the
gastrodie})atic omentum : other- that the deejier o|)ening he
made through the gasfiocolic omentum: this is the more
iiccessihle route of the tu(i. and lictter placed for drainauc.

A stone in the common duct may lie left until the state of
the patient is les- critical : the drainage of tlu' gall bladder will
I'Heet the immi'diate improvement re<[uired.

' /..!',, rt. \,.l I., lltll U. l.V.M.

2-2n

TUK A( l^TK ABDO.MKX

^ oil iHtil iH)t pLicc a (liiiin in the pclsi-. for after- (■lcaii>iiiy
ihc jiciitoiiciini, citlui' \>\ -|ioiii.'iiiL' or lava<ic uilli >tcrili-cil
>,iliMc. tlif |iliii;> wliich arc iilaccil around drainaL't' 1ul>f> >lioiil(l
l)r >iillli(iriil to I in vent furtlicr oca])!' into the ;,'ciicral cavit v if
I lie |)criloii(iiiii. Stroiijr {i-li;.Mit >utiirc- pa^xd tliroiiuli all the
layers of tjic alMloiniiial wail to iIom' the wound arc tiic licst.
l)i((vi(l((l tlicy do not ol)>tru(t tlic riddicr ilraiii>. A firm
niariytailcd l)aiida!.'c should Ix' apjilicd witli plenty of al)-oilicnt
(ircs>in<;. N'ou inu>t lru>l to draiuau'c Ity the anterior wound
in severe eases and not prolong' the operation and incur
lurther ri-ks hy making; a jxKfcr'ior openiiij.'.

It it is necessary to drain for a Ioiil' ])eriod. a ventral hernia
will eeitaiidy re>u!t. and it will he well to explain thi> to the
fri<'iids duiinj,' the coin-e of the illiie~-. It caiuiot he aAoided.

'I'he phitis>hould lie removed after t hiily-six hours. i:ra(luallv,
aceordinu to the amount of pain which the adhesion may
cause. If the wound becomes septic the administration of
<_'iis and o\y<ren, Hiid the early removal of the pluiis. is
indicated, and the insertion of others after a clean-i:i<,' of the
wound with an antiseptic solution.

r , , '

AC'ITE T)ir..\T.\Tl()N Ol' TIIK StoMAI II.

This is a rare condition, the cause of wliich is often douhtful :
at other times it follows an o|)eration or injury invoKinj: the
peritoneum, and it is with these that we are most conccnicd.

An attack starts with copious Ihiid vomitinji. epitra^tric pain
and distension, which Ix'comes i.'eiu'ral ; the action of the howels
is irretrular : signs of extreme collapse are present. Towards
the end of a severe ease compli'te atony of the stomach mav
lead to cessation of the vomiting.

Of physical signs, the most valuahle. wlicji it is present, is
sueoussion. but it is important to remember the possil)ilitv of
the occurrence of such a condition in tl;e acute abdomen.

I'ldess relieved by evacuation of th(> stomach contents if
Usually proves rapidly fatal. The extreuu^ di>tension of the
a])doin(Mi and generally .severe condition ma\ lead to a diagnosis
of acute ])eritonitis. or if there is eonsti|)atioti intestinal ol)strue-
tion may be thought to l*e present. A few notes of a cas(>
will brinti this condition more fiillv before vnii.

- .'ii,. I jt \

T^W^W^^JSe^'^^.

?ir '•.z*

I

OTIIKR CAUSKS OF TirK .\( I IK AHDO.MKN 221

(»ii .laiiiiaiy I'l. I'HU. I was nski-il \<> >.■<■ .i ;-ii| ,,f 1 -,, ,vIh. Ii.i.l Ih...ii
uii'lcr ciirc for two (l;iy». iii coii-^fciuciirc ol ,iu ^ii-iilf |(iilini.n.iiy allVr
tic.u. lint tlicic liiiil lirfii 11 >iiililcii ili:iii:;i' iii lui >\ riiploni-. >]„■ «.,s
till' siil.ji'il ril aiit'iiliir cmviiliirf i.f the (Inr^nl spin,., tin- n-iilt nf ,,lii
tulicrciiliiiis iliscaso.

On till' -Jlst slic licyiiii III viiniil Mill. Ill 7 .im.. 1 1,|. v,.niii.-,l iii,il<-iial
l.iMiij; 111 .1 liilioiis ciiariictcr. iiml mIIuu in inlnnr. IJir \„<\\<\~. .i,i,.,l
iit H M.iii. The pain ill till' >iilf i.r ulnili -lir li:iil imiipi.ini.Ml m;,s
mill'll lirllll. lull Ihr .iillslMlll Volllllln- Ml.l-k.il .ill nlh.T >yill|ili.|||s.

'(■.■MiiM'iiiHiiv. !i!t : piiUf. xn, Noiliniu n invcl ilir hiUiiis,. ri„.
iil.ili.ini'ii \\a> lilriiclrii. (lull all <iv.t. ami willimil (.ii.liiii.— ,,ii
)iic>sm<-. At »> p.m. shr was i.hIht I'.illap-iil. Ihr VDiiiiiini: .•onlliini-.l.

ami now shf was luinvili;; up a l.laik. tinaiiuiis lliiiil. S|i.. ji.nl n-

|ilailiril ot Mil Jiaili siiiiT tin' \ iMiiil ilii; imimc iin. ImiI I lir aliilnini n was
JMidiniim (ll>l.'iiilril. .MmiiiI I l.;!i( p. III., win 11 I ~,iw liir uitli l>r. Miiluir.
Ilii' abdomen was suMuvlia* ili-limliil hiit nm maiU.illy >,,, .liiir.iii'
percussion all over lli,- ii.mt ami ilnuii ilir I,m ihmk to roiipan's li^ta-
Iiienl. No (liilness was piv>iui m n-lil ll.iiik. .\ well-m.ii ke.l tlinll ot
lliiiil CI. Mill lie lelt in the lower pan. anil to the lelt. There was no
ri-iility. Her jiulse was rapid, (aee pale and sunken, .•iiijriie Mack and
iliy. whil.-t theie was ire.|ueiit viniiilini; ol a lilack. larry Ihiid.

.\li incision in the middle line >1io\mi1 a greatly ili>teiidiil stoniach,
the lower mar^'in ot which passed down to the pul..-, ; it w,i> Minsh in
apiiearance and flattened with vet v thin llaceid walls. .\|| ihi. ini, stints
were em))ty. 'Ihere was no tree lliiid. 1 iiMiioinii .ipparently casi'd
at the third part ol the duodenum, and no pressure eoiild emptv the
contents ol the stomach alony; this jiait. A tulie was put in. anil the
openiiiv' sutured to the alidominal wall. Much lilack. Mood-stained
lluid was drained olT Irom tlii' stomach liy this tiilir. and vomiting'
ceased ; hut otherwise little re. id was airoided, and tin- patienl died on
the' followinu day apparently Irom eNliau~tion.

Mciv \\itli acute syiii|)tnms we liiid (hilii.s^ .iloii^ tlic iiiiddlt'
line fur llic first tiiiir in the aciilc ,il)(i(iiiirii.

As iui cxiim])!!' (if tlic (li.scasc fullowinir .in idxiuiuinal i>|iii'a-
tidii a case' ma,v he uivcn. as it iliustralcs niaii,v iiiiiKirtaiit
points wliicii may (ii\ -lop diniiiL; tlic course of sueli .in iliiicss.

A woman, aj^cd 27. came under my ear.' Iiom the late Pr. Ilcatli, of
i*t. Leonard s-ou-Sea. on Xo vein her 7. I'.hiI, toi- a -welling- in the ahilomen
which liad heeti noticed to he increasinn- lor tin' |iievious nine years.
On Novemher 12 a ccclioliniiy was jMiformed. the dia;;nosis of ovarian
cyst continued, and a, laijrc tumour removed iu the usual manner.

On the first and second days after the o|ieratioii the jiatieiifs pulsn
was aliout 110, and tctnjierat lire rose from !ii; to lu.'i". 'f'lie abdomen
became incrcasiii^dy distended; there was no vomitinj,' beyond that
directly following the ana'stlietic. A week after the operation theie was

' :>ue Laiurt, IV'i.M. \'ui. I., p. {> U.

^^^''^Ij^^SSST:

H^i

TIIK ACiri; AIUMJ.MKX

oviiliMR'f i»f sli«lit supimrati.iii in (In- alxliuiiin.il wnimtl. ami smriK |>iii
was evai'iiatiil «itli a ilmcicu . 1 licrr .1(11111111(11 to h.' mvat ilinii ii-itm
ot till' aliiliiiiii'ii ami iniii'li iIi-thiiiIoiI.

Oil Noviiiiliti- L'l |)r.('. I!, |!i,\ ,a« I: .1 w u h mh'. I hi' i|iii;a>l lir ana
was tlicii viT,v |>ri>inim'Ut ami a iiiimiiii.' icmii ~(>iiiiit iniilil lir nl.laimil

over this arra ami ivlimliiiu ilnu uwani- lo ilir ili i.»i>; maikcil

HiirrilHsjiiii was I'ljciliil uri -liakiliy llir |ialii'iii ; iji.ir \\ii> n,, mhuiIiii^'.
I.avap' lit lli)> ...tiiiiiai'ii was nmiiminiil anil caiiiiil mit I u iii- il.iilv Irmii
this time, 'rwciily-six tlays all. 1 ll.f opi r alum |.aiiiiili^ ilivilnpiil,
assiiriati'd with a sfpiira'iiili- liiii|., lal iiri' ami siviir iliai 1 lina. ami liir
Hiiiiif tlays this was iilinilitiiillaMi'. . \ 11 1 1st • ipi, „•,„■, .j, ■»,. ruin was^riviri ;
a maikiil ia>h tnllnwri! twii ilay- attir il> ailiiiiuisiraliim. imt it was
willioilt api.airlil illVrt on llir iIi-imm'. Tlii. (|i>|iu.|iiu ol the alMli.im'U
liiil md appiiriahly illmini-h. ami with a hiuli liriipi ralun' ami the
ilianhua it ri.iiliiuiiil Inr aboiil ihnr imiiilli> ; miii'li nilfiiia of hoth
h'Ks ami the lower jmit of the al>iloiiiiiial uall siipii \ iiiiil. Soni«
peristalsis in the le^'ion of the uniliiliiiis was mca-ioiially seen, ami the
stoliiaeli still showeil the physical >imis of dilatation.

Oil Ai|i;iist 11', I'.Mil'. the naslio-int.Miiial liimtious hail l.eioine
praitieally lioiiiial, the leiletiia in the hiwir part of the l.oily, ilm;
plesiillialily to lliroml)o-is of the inlilior \ena cava, was still present
ami the palient left the hospiial. .•Seen a^aiii in .liiniiaiy. l!iii;t, her

general health was m I, tlioii;;h eviilence ol lhioiillii).-.is persisteil, there

beiiij; soiiK! le.leina of the ankles with ililalalion of the veins over the
lower jiait, of the aliilonien.

The siihseipienl history of this ense is very iuterestiiii;. She was
reailiiiilleil iimler my care on Novenilicr l!l, I'.iiiT, for another aliiloininal

swelling. !t was staleil ihal her genera' healtli hail lieeii a I iinlil a

fortiiiKlit hefon . ' ' that iliiriiij; that time she hail snlfereil fioni jiain
swellin;; liiM no voinilin;;. 'liie ahiloiiieu was a

ill the st(iiiiav.!i

Cooil ileal ilisiemleil and tense on admi»ion. the superlicial veins
dilal 111, ciiielly in the lower part, and t here weiiniiimiousliuea;all>icante.-,
in the same ri;;ion. .V dull loumliil an-.i was present reaching; almost
to the iimbiliciLS from the jMlvis. TJiJ., \v;,s Unit iialiiiu and tender,
whilst around it the intestines were diste'uled and tyin])auitic. Her
temperature \va.s sli^ditly raised, .-ihe was keid in lied for some time in
order to jjive the inllammatory state a chance of i|uietini,' down, hut tlie
distension did not apinecialily diminish. On lieceinlur 4 an incision
to the left of the middle line was made, and an iiillanied ovarian cy.st
reinovid. The iiedide was long ami had been twisted iliree times froni
left to ii;;lit. 'J'he cy.st was very adherent to the onientuin, but uot
supjnirating. It was an ordinary miiltiloinlar cyst. The gut was very
much distended, the sijjnioiil beinj; about o indies in dianicler w lieu
exaniiniMl in .,ie wound. It was not pmutured, as the comliliou was
regarded as temporary iu character.

Much tiatuleut distension of the abdomen coptiuued not involving
the Ktomach ; many remedies were tried, but 11. .til the employment of
the interrupted current late in December no delinite etfect appeared to
have been j.roduced by thrm, but the disteusi.m tiiuldiuiv subsided ou

TT

OTjrK|{ c.M-SKS ni' ri||.; A( itk \|-|„,\|| , _.o.,

th.^ '.V.ll. of that mouth. Th. ,,• «.,« >,., ,„|,,M„ai ,„. ,.| !,■, , ,.

tiirt- alter tho (i|M'r.it

Ih.' miiiMial aniount ul .liM.n,io,i ,,| ihr inlrMii..- |m.-.,ii .,i i|,..
Iim.' ..t til., .vvori.l a.lnii,,i,.i. aii.l th.. <|iili.iili v in .iiii, ■ .hi ,,| ,t m,.,
niMialh.ii IS ..H|»...iallv iuf,...|.ii;; in ., iMiLia „,,!, i|„. Im-'.mv ••„

tills .M'casM.ii tl r... v.a. 111, Ml ii.iii,.,. .nh. , ImI , ,,11,1 .,..t„.,i

Vft th.- .Ilsl,.a,i..li «as ..M ,,.,i,r. lu.j M.uu. -f.l t h.n I !„■ „. , ^ .„„ ..|..,imm'
was ail liii|M.itaiil lartoi lu its .•ai„ali,.ii. Th.. ..,|,|.l ..,,,\, ,\ .„, i h.

us.. „l th.. iut..iTU|.t...l .-mni, ,|iiii.> t|,„ M.u. W. K,i„» l,„«

luaik..,! th.- ■THl.v- ..|r-.-l „.;.,> I,.. ...MHliM. 1 .u. i„|,nv t.. t h..

alMl„i,i..u u.iutt.lul..,! xMlh „l.v,..,„ I,.,,,,,,. ,,|,„ Mm .;,.al ,l,s|,.„„..u
\vhi..|i may .'Usu.. ..ii th.. m.i.. aii|.li. mii,,u ,,i ., Iii;.,i.n, i,, i|„. ,,..,l, ,,l i

h.;iuia!sa..mtli....,,..iali„ul„i ia,|„.,,lr,i,,.. I „„„.•,,.,•, mi „l,i,.m

ul rapnl ,list..usi,„i .,( H,,. alMlmu.,, vm,|, paiu. \,.,i.niim ,,,hI .. i..„i|...ia-

tur.. ..I I.i;i-.l ..usu..,l with a ...illa u lu.j, .^,.,,,.,1 ,la,,n. Ai-i-ioiHiat..

r..Mi...tu..s .s».,u i„oilii,...d a diauj;.- |,.i- tl... I„ it,,- au.l ll a>.. lau tho

ii^ual ast.jitic ».(>iirs...

'riii'-c fast- ;m. botli .,f f|i..„i ..\,iiM|.l.- ,,f ,1.111.. .Iil.it, Hi. ,11 ,,)■
III., stoliiiicli J.iil |iiv-,iit many |M.iiit~ .,1 .■.MiliaM. In th.. |ir-t
tlir stuJUacli ha. I lu'cmi.. a iii.tv lliii.l .■..iil^iiiiin- -a.' \Mt,i a
tliii. wall, \vl,i,.|i at tlif iiiiK. .,f til.. ..|M.iali.,ii ua> Ivii.L' <>^ry th,.
fi.-i.t ..f ll... iiitL..stii...s an.i Kav,. a .lull ii,,t.. ..ii |...f.'ii~-i,„i a.f.iss
tlic. iiii.l.ll,. ii,,,., ;,„ af,.a, wlii.h is ,v-.„ia,it i,i all ,,tli..,' .• iiti..,w

• 'I thf iiciiti. al..l..,i„.|,. 'I'h..,,. wa- „„„, (■.■itaiiilv ,io .J,,-,..,,,..
a,cuiiuilati..i,. a„<l ,ii,iil <|„it.. th.. Ia>i .laL". t l,.-,v u,i , „., .listfii-
:-ion.iftli,. al„h,i„..,i. h i..|,tli,,ih t. .,■,.■.■,,„„, lutii i,,il..,-w,.
a.'.'i.pt thf su<.'.4,.st„.,, that it ua- a |.,i,;,l\ m^ .|,„. i,, .,„„.■ l...xi..
<'oi„l,ti(.i, asMu-ial,.,! with th,. |,a.l.h ..I |.||ia„i,ii,it i.,,, ,,t th.. [..ft
lili.^'t..Ui..ll.y|),-. Kill-..,, u-|i,.„h..|i,M -„« tli,.|,ali.„t. .S|,„ial

• Icforiuity ha- l,.-,.,, i,.,ti,...l i,, ,,;h,.,. ,.,.,.,- ,,t a.i,i.. .Iilatati..ii.
but wh,.iii„it as>,„.iat,.<l with t h.. a|)|.li,ati f ., |il,i^t,.f ja.k.t

is .liHicuit t.i i,„.i..,.,ta,,,il h.iu it .■1.1,1.1 ha\c iini.h iiilli,.-.,,.,.
.. liic |)f.Mliicti..ii ..f s„cii ail acute an. I tatal athrlion.

l)r. W. 15. J.alV..i'c.)ll,.,t...l a -.ri... ,,f _>I7 n|„ut..i .aM-aii.!
of tli<.s,. .•i,s-i' j,,.,. ,.,.,it. f,.||.,w,.,l ..|„iati..ii-. iiMiaJlv ..ll.. ..,1 llie
abdoiiin,. The ,i,.t..s „f the s,.,-.,a,l .•,■,-,. ^u-vr i.'i.l.li-h.-.l l,y
Dr. Box ati.l myself on aceount ..f its laritv, a-i.l a- an ..n.'..ui"-
ageim.iit in (he Ireatmeiit ..f si„.li th.spef.'ite ...ntlit inn-. We
are inelitied to put its occurreiu'e <l<m„ to sum,. i,,.^i,. al.M.,pti..ii
from tile wouiul, altliougl, tli,. amount of siippt„ati<.ii was
iioitlier acute nor e.\t,.iisiv,.. It is piohal.l,. that sli.- .nv,,! iier

•■ .VnnaN of .--iirmTy." Vol. ||., \'jn^.

.'.'I

rili: A( I'TK AllDo.MKN

111

..III

if)'

j 1

t ;. .

\

r^ i

nrovcry Id the f.irt thai li.i (li-l.ii-iun wa-. ucncial itnil not
nl»-nlut(|y cuiiliiiid In |||i' stoiiiacli uikI iliiodcmirn.

.\> r'>;.'ar l> till- (•,iii>.,iliniMit aciilr ilihitatiuri i>\ the >lniiiarli,
ihf tidlnw ii|._r (.piiiiiiii may lie <|ii(iti'(l ' : —

I lil^ iMU»r wr liniiiil. allii t\|>ci inii'lil^ nil llic radavcr. In In- llii'
|ii<>«iiri- I'Mili-.l li\ tlir -ii|i.iiiiiiiiiilMiii ami ililalid «(i.iiiacli mi thi>w

jtuits III till' iliiiiili'tiiiiii whii'li III' III 1 1 art vMtli tlir liiitil atld li-lt nult'

III till' >|iitial injniiiii \\ ,' Icamiil latii that a -luiifwlial -Jiiiilar
Kiil.'>r<''>'i"'i li.i'l ''HH iiiaili' li> \li'\.'i ill iHH'.t, ami liy .S'lnilt/ in Ihliii.
Our Iiv|i"tlii'-.w iH that III thi' iHiiiliK'tiiiti of the train ol »> iiii>tiiiiirt,
a^xiiiatiil with aiutf ililatatimi nf the >ti>iiiaili. a virimis .inli' rami'
into pla.v ; lii-t a |i:iiiilytii' ilil.itatiun nl iht' \iMii» oii'iirti'il. ami thi'ii
(li»trii»i<iii, iliii' til ilmiili'iial iili'tiiiitiiiii, imliiri'il liy tin- weight id tii«
siilii'limiiiiiliriit -liiiiiach."

Altlioiiuh the itiMTlinii (if a t iil)f atUT aliiloiiiiiial section into
tli<' stntiiacli lia> lii'fti Miccc-sfiilly tried, your main rt'lianci-
shmild l)con piwilion. atid the \va>liiiij,' out tlic>toma(li witli tlie
stomach piitii|i or si|i|i()ii. 'l'||,> patient mii'.t lie on the right
si(h' Avith tlie head low.

E.Miioi.is.M AM) 'I'liijD.Miiiisis (>i Till; Mkskntkric Vesskls.

This i> very rare. 'I'he re-iilt- which follow oi)literaf ioti of
the ve>seN in the ine,-eiitery are the •-anie wliieliever vessel
becomes first affected. (Jaiijircne of the mit invariably follow.^.
A mail belweeii :!(i and (i(> year- old has ai, abrupt on.set of
sudden intense pain in the abdomen, followed quickly by
vomitini^ and collap>e. peritonism is well marloxl. If diarrhwii
is present the tnotions are fre(|Uenf and blood stained ; if
coiistipalioii. tlieii notliiiiL'. not even flatus, is pas.sed. The
abdomen is distended, rij^id and tender. Sometimes free tluiil
is jiresent. 'I'lie timperature is ofi.ii -.idinormal. the pulse
rapid and of bad (piality. In the second smaller group the
origin is insidiou- and the proLifess varies. A diagnosis of
intestinal obstrudion may be made. l>iU the true condition is
only found at the po>t inorliin examination, (ierhardt gives
the tollowing as necessaty for a tliagnosis : — (1) 'i'he presence
of a source for the embolus ; (:.') copious intestinal lia^nor-
rhages, not to be explained by disease of the wall of the bowel,

'■ C. i:. V.r,x :i:ui C. r. \V.,ii,icc, •■.\.:i.;>. Diiat.itiuii u£ the Slomaoii,"' Lancii,

Vol. II.. I'ji:. 1.. L'l.-,.

OTHKH CAU.SK.S UF TMi; .\( Tl K \IWm.\||;.\ :■>.;

<•!• I.y iin|H'.lini.'iil |„ ih.. ,„„.,,,| rini.l.aiHi, ; (.i, ., ,,,|,i.i .,,„|
ri.,irkr,l tall of l.lnprrulmv ; ( ») ,.,,li,ky paui iM ll... .,Im|.„i|.
(••>) the Mi.mll.iiHun. .,!• |,n\;„ii, -Mriirnn.r ,- ,.|,.Im,||.|i lu
"""•'■ l'^^''-' <•'» ""■ '"■•■^MnHal |M. „.„.■,• ,.!• a lum.a.r ,„ tf„.
'^'"I""i<"- '!".• t.. Il.c ii.lillralinM nt ih,. Mi.vni.iv uitl, 1,!,„„|
All ..t tlit-c M^ris iuv iKit. Imwfv.T. pivsrtit in .v.'iv . a^.

Tl... oixTiitiv Irvaln.nit ,„n-iM> i„ a nM,ii,,n .,i iln- pari ,,|
the 1h.\s..1 tliiit apprar^ invnUrd in (li,. p,,,,,..- ,,t -aiiL'i.Mir ainj
"i" placing of an opfrnn;; in ihr Im.u.I at a ...nv.iihnl .p,,i
alM.vc. 'I'lii, i, ,l,,n.. (I) iMvauM- in iVMctmn ..f a porlmn ,.f
mil. the lin<' nt Milniv, if anaM..ino-i> .if th.- Im.uvI j, |., |,,ll,,u
imi>t l>r inMHrnd ti.Mic, an.j it i- ahvav^ .lunl.tf.il in ili.^r raM~
'i til.' UMiiunn.. v,,ll not .p,,.a,| ; (-) tlir full op.,ation n,,nl(l

'" ^' in>tan.-f> tak.- too lon;.r uiim . onM.hraiion i^ pai.l i,,

tlif^^iavf sliitf of tlic patient.'

l'i:i{U)it,vTi()Ns oi Tin; (i.M.i. im.addci; and I'.ii.i: im < is.

Symptom- of peritoneal invoKcnirni of xariaMr r\tcni ariM>
citiicr from perforation of the ^ali hlad.jer. or from il. I.em- m
a state of plileiiiiioiioii- or j.Mn_'renon, iullamm.il ion. .\ In^tT.rv

<'t I.reviolH allark- of hiliaiy eolie. perhaps .("oriaKd uilii

jatiiKJiee, may very likely lieuiveii.

The pain in typical ea^-. will }„■ loeaiiMil in the u,, 11-1,1,,, j.jer
K'^'ion. hut it m.iy extend l(. Ili, iinihili.ii-. I- i he .ipjh ndi.v
iVL'iun. or i)eeome uenerali-eil. in ac((.r.laiiee uiih I lie extent of
''K'Nifeetion. IJeterre.l pain in theriuht -hoiil.l, r i. in .tnmon,
Coiitn-ion in (lia^'iioMv uiih ;n iite appeii-lK iti^ or prrfor:ti,,n of
■■* 'liiodenal ulcer is likely to ari^'. Th.. follouiim I- an ■ -s.iuiple
of the former type of ease :

''iilli.-.-v.-)iiii>,M.f N„vciii1m-i it. Kt.i;!. I \ ,|,.i|ii.M.-.l I. nii.iti.'iit,

:l;.'.'<l .->H. ■j-uo days l.,'|,,i,. |i,. |kk1 |„ ,.„ ,,,k.mi uiiIi -r\,i,. |..iin\vMu;:l'
ab.liiiiimal jiaiii a.-.wini|i.iMJc.l with v.lI^itlllv^

lit' lia.l ha.l llii.c ,.ili,T attack- of ali.i.iiiiinai pain, tin- lii-t • u> years
l>icv!.m,|y. \,„i,. of tliciii ha.l Iic.mi tellowc.l l.v jaumh.-. . aliiioii;;'ii th.-
|.ani was always in the r-Mrioii of tii.. o;i||-l,la<l,l.-i', aial ih, y w.t.- i.J!.nl.Ml
as liihary ...he. -I-lio j, resent atta.'k licKaii .hniu;; tiir iiiuhl "i .Saturday,
the Kith, aii.l ifseniljh'd th.' otlur attacks. Ou the iKth la f It s„ mii.'h
letter tiiat he went into the City to t)usinrss. In the cv. nini,' h.' .Mine
honi.. e.irh.-r th,m usual, and sent for 1 >r. Gotlfr.-v, wli.i loiin.l liiiii a-aiii
conuiiaituui: of pain in the ahdomeit, with a tempetutun- of ha . cni

' Jloyniii.iii. .U.ii.iiM.nul (ii,oiali.iii«.

A.A.

Hif^M

hi'

iii'

I i 'I ,(!-.■

226

THE ACUTE ABDOMEN

the follow i;,^ iiioruing lie was worst", and iluriuf; (lit' ilay lit^ hatl occa-
sional voihiiiiig; the al)tloiiiiiial pain coiitiuiicd to lif st'vt>ii' and
f;i:i(lual uistf'iisitm cainf on, whilst liis fxpifssitHi bccaino changed to
that associati'il with scrit)iis abtlmninal iliscasc.

When I saw him about 11 p.m. hi' had a gifvish look and appeared
distressetl, Tliere was occasional vomiting. His ]mlse was 84, of fair
strength. The abdomen was distended anil tlid nt)t move well with
res])iratit)n. It was tentler on pressure, especially on the right sitle
Jielow the ribs, the area of most markeil tenilerness being midway
between the ribs and the iliac fossa. The liver dulness was not increased,
but there was some didness below in the riglit tiank tlillicult to duline,
as the man was very fat. 'Jhe bowels had acteil twice during the day.
He was eviilently suffering from peritonitis, but we could uot decidt?
wheie tlie oritriu of the trouble was. Incision over the ihac fossa
showed that to be healthy, whilst there was pus along the colon cominu
from above where the intestine was covered with lym]>h. A second
incision over the gall-bladder showed a recent peritonitis arountl it
with pus, not definitely localised. The area atfected was cleansed,
antl the gall-bladder examined. It was small, not distentled, but
l)rescnted a small perforation near the fundus. Xo stone could be felt,
but the condition of the patient under the ana'sthetic was bad. and it was
imperative to finish the operation as soon as possible. The gall-bladder
was therefore packed off with gau/e, and a tube introducetl above the
plug down to the opening in the gall-bladder. The patient recovered
and has had no acute abdominal attack since.

The case8 may be very acute m their course, and early
operation affords tlie only chance of .success. The jieritoneuni
fills rapidly sometimes from this source, and as a rule there is
little in the previous hi.story to point to the presence of gall-
stones in the gall-bladder, as they are usually of large size,
giving very little inconvenience to the j)ossessor until ulceratii)ii
has taken place over them and extended through into the
peritoneum. Occasiotially the symptoms may not be of this
acute character.

It is possible to get large accumulations of fluid in tlie
peritojieum after perforation of the gall-bladiler without the
production of much disturbance. This is well known where
there has been a traumatic rupture of the gallbladder or bile-
duet, but a rapidly fatal peritonitis is the usual consequence
Avlien the contents of the gall-bladder have escaped through a
breach of the wall in disease of that viscus, when micro
organisms are very active.

The condition of the ])atient will not often give the oppor-
tunity for an excis.jii of the gall bladder. You are usually

OTHER CAUSES OF THK ACLTE ABDU.MEX 227

restricted to draiuage of the galLbhul.!,.,- aM.l ,.erit,„„.um 1),,
not ^get t..e tendenc, of .....a ,,,...1 , ' ,..., ;,Z ^l

Perforations of the gall-hla:l,h.r or h,l..-,h...... tin.u.h hv no

means frequ.-nt. form an important .la.s j,. ,.„ , \ •

abdominal eatastrophes. Meu-i,,,.,.; „:ui ..:;':; '::';.;;;

from general medical literature.

In a series of 3.180 operations on tlu- l.iharv srstrni there
were only 29 eases of perforation, or l..ss tl.a,. I p[.v\Zt

I>r. C. Campbell Ilorsfall has reoor.kil ' tli.> <■■,<.. -f
whom he openited for a perforntio t ,h oV, 'i V'T" "' ^'' ""

after it. occurrence. The pa.ieu a ... '"",'"'-'■*'"'■' "'" •'^'>-

to see the opening, but drainage was pT o'i. ie o ,. "* '.'"' '""■^"'''^'

bile wa.s co,ning. and tubes pi;,...., i,, .'V , , ^^'^ '"'" "''''-■''
the pubcs. lie says that '.McWillian s ol . . ;.t ;^, .'""',''' ;'"'' '"'''
amon^sT the series of Ms i-erforations of ,he i i - Z; '''"'

(1) ii./o-. -Female. 51 ; sympton.. four .v . ' ' '^"^■

duct ; cholecystectomy. ^ ''^ ' l"''''''""-" "t •■onnnon

(2) Hiedel.-ilale, 56; svmiytonis fl.i..,. i

cramou d„c. a,.,. s.ll-b^;ijei I 'SScv..r,,,f '" ' """"■'«"" "'

Recovered. ^ ' '^" ^'''' = (^''"Ifcystectomy.

The above five cases show in a very grai.hic m-uv the ininort
anee ot early operation in these eases fn tivn th,
had been in progress for four an.l ,1 ree ^yZZ^X'"':
...th died. The other three were operated ^n :^:u'£,:t
hours after p.-rforation. an.l all recovered. '

Occasionally the symptoms may not be of tiiis wM.to i
patient under my caro in 19(.8 ^v^.s .ulmit e.l '^''facter. A

..Instruction. Ile'was a feeble oh maf w ^ n 1 '"T""'^ "J'^^^'""'
length for some time, .hilst tlirabim ^ L 7";. ZX^r' ""
distended for a week or fei. rl->,-- i>of i gi.uitially become

he had also had! hn.:\^n:iH;^,r:m:;;;:;:r'' Tir"v;"^^' ^""•^

distended, it contained a larpe .nia.ititv of fl l ' ''"'"""■" ^^-'^^

emaciated and raiher yellow in . ,'■• mc I "'.' '"'"' ''■"'

had no pain, and at this time ^sZ'^^ZnJh^'ir":^ ?'""^"='
was suppo.'ied that he miL^ht b.,v,. ",' ^ """'""' T^ ^'^"'" the history it
the large bowel „ith. 'on, -tt .'u^ "'alignant obstruction of

' /iritu/i Medical Jounuil. lyi3. V,,l. II., p. ii>i.

His pul>c waa

g2

i

iiiii

s

228

THE ACUTE ABDO^IEN

not more than 7o ; his tf^inpiTatun; was normal. An exploratory
operation was done and the poritoneuni found to lie full of hile-stained
fluid. .><eareh was made for a jiossilde cause of ol.struetion. l)Ut the
intestine was nowhere distended and no «rowth could lie felt. Some
lymph was seem in the region ol the (;all-l)ladder, and amoiifjst this
lymjdi was an opening which led into the jrall-hladder. in which there
were some gall-stones. The patient did well for a few days after the
operation and then rapidly sank and died.

ENTERO.SfAS.M.

By this term is now ircogiiiscd a comlition in wliieli thorc
is a spasiiioilic contraction of the muscular wall of some part of
tilt' intestines ; tiiere is no obvious structural change in the
bowel, and the phenomena are usually regarded as being
dependent upon some abnormal action of the nervous
mechanism.

The spasm n y give rise to symi)toms of varying intensity,
from those of chronic constipation to such as simulate acute
intestinal obstruction.

Dr. Hawkins tlrew attention to the condition in 1000.' and 1
will give some of the conclusions he then set down.

Symptoms usually manifest themselves in patients during
the active i)eriod of life ; they appear with about equal fre
qucncy in the two sexes. The individuals affected are usually
of a neurotic type and often of sedentary liabits.

Opportunity for direct observation of the sj)asm of the bowel
does not often occur, but Dr. Hawkins thinks that the colon
is more often affected than the small intestine. The pain in tlu'
subacute ca.ses is sometimes localised in the right iliac region
and so appendicitis may be simulated.

In one case under my care some years ago the i)atieut, a man of 50,
rather stout and very ueuiolic, had a swelling in the left iliac fossa, with
occasional ha-morrhage from the rectum. These conditions were due
to spasm of the sigmoid associated with internal ha>morrhoid«.

I need here only consider the severe cases giving rise to
symptoms wliich suggest tlu> necessity of immediate operatic
interference. Sometimes the resemblance of the condition t-
intestinal obstruction of organic origin or even to general
peritonitis may be so close that the mind of the observer i-

' Jiritixli J/tliCjl Jonniiil, Jiitiu.iiy lH. \'MM'<.

OTHER CAUSES OF TFIE ACLTE AHDOMEX 22!)

left in doubt as („ the right .liug.ioMs. aiui ,x|>lnrati..a .,t tl.,-
iibdomcn will he the (.iily soiiiul couin,. to pm-,,!,.

Points whi.'h will 1„. |„.|,,t„| \n arriving at a .IcHmo,, a.v I ho
jmsonc-o of the trouble in highiy-strung, nciv.m. in.livi.luaU
with a history of previous atta^'ks of ab.loMiina! pain similar
111 character wiiich have passe.l olf without op.-iat.oii.

In a case operated on for lue in St. Thomas'.. Hospital by
Mr. L. Xorl)ury ;

The pali..ut was a woinau ..f 4.M.,,- wl,„„. I had r.nu.v..,! <'M..u,no,
about two yoa.-.s i„vvi,M,sly. IIv .syniptoius w..,. ih-.s,. of aratc
lutostiuu oKstru.-lion, and tlic spasinodi.. .■o,ma.-t,ou If..,.,,.,! ,n,„.|, of
th... .n.all latest in,.. .><l„. was a lypical u,.ui-o,i.. i^ api-.-aian,....

1 have met with the condition as a i,K.alis(.d air.,! ion of the
splenic flexure in more than one instance. H,.,,. the patL-i.t.
liave been overworked and an.xious men of over 43 vears ,>f
age. I'ldess abdominal exploration has bet.|i (arri,..! out in
any case ()| ab(h)minal pain, it is impossible to - .v that it is
of neuralgic (.|iara(.t<.r. I have known seviv 'atta.ks „f
recurrent pain put right hy the division of a band.

Torsion- afkkcti.n,; otiikr Audo.minal Stkk ti uks.

Many other exampl,.s of torsion of a pedich. have I, .en
recorded m me.lieal literatur,.. such as th.. spie(.|i tlw .r-dl-
bla<lder. the appendix. M,.ekels div..rticulu.n. an I inore
frequently, tumours with a movable attachin.n,, smh as.imul,.
growths of the small int,.stines. cv.sts of th(. iiH.,sent,.rv Jn
hydro-.salpinx (or jiyo-salpinx) the tulu. oc.a.ionaliv becomes
twisted.

Torsion of the great omentum is a lesion to wlii(.|i Mr E M
Corner has drawn attention in the St. Thomass Hospital
Reports. It is rather m,)re commonlv iiu.f with than most
of tho,se coniliticms which we iiav(. mention,..! in the last
paragraph. Not infrecpiently it has been .iia^'nos.. I wroii>r|v
us appendicitis, but usually th,.rc is a historvof iiiir„i„al hernia
on the side of the swelling or a hc.rnia mav be present. The
.^ize of the swelling, which .s nio.stlv siluafVd uni.r th.' .-i.rhl
rectus, and the .slight nature of the symptoms consid,.ring"its
somewhat rapid foruiation, are against an intlammation of the

230

THE ACUTE ABDOMEN

•:^ I

appendix. It is also more movable on the deeper structures
and gives the impression of ,i solid mass.

An incision should be made over the inguinal region and
carried ujjwards as high as necessary along the front of the
rectus sheath, the muscle being displaced inwards and the
peritoneum divided with i'c posterior layer of the sheath.
The ujjper part wheri' the twist has taken place is not very
broad and is easily secured with ligatures. Early operation is
desirable because of the danger resulting from gangrene of the
omentum involved, but successful removal of tlie mass, which
is sometimes as large as the adult head, has ])een effected after
the condition has l)een in evidence for a long time. This has
usually l)een during an operation for irreducible hernia. It is
interesting to note that many of the subjects of omental
torsion have been sufferers from attacks of abdominal pain the
origin of which has been unrecognised.

Vigxard's Cask.— a man of 31 Iiad attaoks of pain in the right side
of the abdomen for nine years These attacks ]a.sted four to five days,
and there were lour or five attacks yearly. In tliis patient a diagnoses
of appendix abscess with inflammation spreading to a hernial sac was
made.

Jn more than one the position of the pain with rise of tem-
perature and presence of a swelling has led to the diagnosis of
appendicitis, or partial obstruction has appeared a likely
explanation of the .symptoms. It is extremely likely that
minor degrees of torsion are frequently present in omental
hernia?.

H.EMORRHAGE FROM Ga.STRK AND DlODENAL UlCERS.

Few surgeons have any doubt that operative treatment
is sometimes absolutely necessary in luvmorrhage from these
ulcers. It may be the only means of saving life, but the
indications for its performance must be clear and definite.
It is certain tiiat in a large number of cases w Inch have appeared
to be absolutely hopeless the luvmorrhage has ceased and the
patients reco\ered under appropriate treatment, such as
complete rest in bed. the administration of morphine, saline
solution given intravenously or subcutaneously. with, in addi-
tion, a continuous supply per rectum. Nothing should be given

Hi:

i.i

.^^4»:mfmr^'

l^T f

OTHER (ArSES OF THE ACCTE AIJDo.MEX 2.U

No visitors or Imsiiios worries sliould ]h- pt r-

by inoutli.
iiiittt'tl.

Somi' of tlie puhlislu'd ciisos tlo not had one to tliiuk that
operation was really iieeessary. and tiiat the jjatieiit would
not have recovered without the operation. In a Idition it
should be noted that in more than one instance no lesion has
bi'eu discovered ))v the operator.

If. however, the character of th(> bleeding makes it apjtear
that an artery has been opened up by the ulcerative process,
the rules of treatment must l)e adhered to in the stomach as
in the case of similar lesions in other j)arts (>f the l)ody.

The need for quick and steady operative procedurt- will
be apparent ; the surgeon must lose no time, whilst the deeper
manipulations must iu)t be hampered by an inadequate opening
in the abdominal wall. The patient must be prepared as
usual i!> ;.bdomiiial eases where much shock is exjiected. whilst
the preparations to replace some of the blood which has been
lo<t are completed. If the loss of blood has ])cen considerable,
intravenous infusion of sterilised saline should be commenced
at once and continued during the operation.

A free incision is made in the middle line to fully expose the
ga-tric area; the intestines must be packed otf with gau/.e
stri])s. and the stomach examined with the view of locating the
ulcer. If nothing is fomid anteriorly, then it is advisable to
explore the posterior surface through an opening in the gastro-
colic (mientum. The stomach, having been l)rought outside,
must be partly emptied, with a trochar and cainila if very full,
if not very full through an incision. This incision is made
through the anterior wall of the stomach parallel with the
greater curvature and nearer to it than to the lesser curvature.

This stomach opening is held stretched with retractors and
the interior examuied in detail, commencing with the areas
in which ulceration is most common. The whole of the
interior should be explored when the fiuid contents have been
cleared away. ]>ecause of the ])ossil)i!ity of the presence of
more than one ulcer. TJie use of anyone of the various means
used for arresting the haemorrhage will depend on the size of the
ulcer, its j)osition. attacliment, and the general state of the
patient. These include : —

(1) Excision of the ulcer, and suture of the result insx opening.

* !

232

THE AfTTK ABDOMKX

(■2) I'lidcr riiiiMiii<i tlic tisMics round tlic ulcer with catgut
sutures, or ii|)|)lyiiif: a ligature to the artery which goes to the
ulcer.

(:i) Suture of the mucous membrane over the bleeding
point when tiiis is small, as in the closure of a perforation on
the serous surface.

(4) (!a-tro enterostomy, taking advantage of the opening
already made.

Pylorectomy. which has "been advise<l for some cases of
idceration with thickening, is seldom pos>il)le : the ojjeration is
too severe and prolonged for cases of .such urgency.

I do not advise the application of the actual cautery ;
its effect on the tissues is to produce a slough, which when
it separates may give ri.se to renewed luvmorrhage and septic
trouble.

Sir JJerkcley Moynihan' writes :

" (ia.stro-cutcrostoiiiy, it wiis fitund, led, in all my rases, to an
instant cessation of tlie bleedinj; and to the sjieedy and complete
liralinjr of the ulcer. Tlie e.xplanation ot this was, it seemed to me, as
f(,llows : In all ea.<es of h;ematemesis or mela-na, tlie tendency I"
spontaneous ces.sation is known to be remarkable ; tlie cau.sc of the
continuance (»f tl.(! Ineinoiihajje in certiiin ea.ses. I concluded, after an
examination of .several ea.ses dininj; operation, mu.st be distensicm ot
the stomach." ..." My own practice has justified my advocacy of
this metliod ; in no case liave I found reason to rej;ret liavinj; adopteil it.
In all, the arrest of the hiemorrhagc has been comi)lete, and permanent. "

This is a very important statement coming from such an
authority.

One of my cases of gastrojejunostomy died a few tlays after-
wards from ha'morrhage from an ulcer in the duodenum, one
of two which were present, but this was evidently because the
ulcer had extended into an artery, the influence of the opera-
tion l)eing brought into play too late to arrest the process.

It may be the wiser plan, when possible, to perform the
operation of gastroenterostomy although the local troul)lc
has also ])een directly treated.

In dealing with these cases it is advisable to remember that
the ha>matemesis may be of hysterical origin, for stich a
condition is always amenable to medical treaUnent. and

' •■ .MMlc'iiiinal Ojiciatioiis," J', ll)2.

^ .> >--iX'-^-i'-M'^Wr^iMm^-^&fj^m^WF?^WJ^^^

ll"-|iilal,
li llii' liroip

OTHER CATISES OF THE ACUTE ABr)()MEX 2:i:{

should not bi' >ul)initti'(lto operation midcr aii\ ( iiciini>t,uuc-.
Tlio liistory of tlio case giviM Ix-low not omK' 1i(||,> t,, pn.vr
tliis. but shows in a marked dej;ree the iil>" that may tnlinu-
sueli ill-advisod interfereuee.

A iiiirM', ajicd I'it, wiw >eiit to nw hy l»i. Frank H,>\all. m Itmhwick
m .<.'i)teml...r. V.mi. for varicose veins of tii.. I.fi l,.;.', whicli u-i.- causiii.'
her iiaiii when slaniliiijr. Sli,. «as ailiiiitled to Si. 'llioiiia>
ami Treudeleul>erf:"rt oiK'ralioii with evci-iou of sonic
prominent veins in tiie ealf iierfoniied.

JnherpasI l.i>tor,vit was slated t|,al .sIi,. had Im.h i„ anollirr hos,,iia|
asliort time Infoie forsymi.lorM> whicii w.iv i.-ai.h.l as imiieal ini; tho
Jiresenee of a irasl ric ulecr. One ni>.'hl she drvelop.il anile svmi.loin..
wliicli were sii])i>os(.d lo liave l.ccu due lo jx rioialion of the 'iilc..r. ami
an exiih.raiory incision was made in the e|.ijrasiii<' i,-i:i.in liy a siiix'.Min
wlio fouml noiliin.i; but a normal state of th.- stomach ; I line liinriieen
no perforation.

From tlie liistory lliis was siip|)oM.,l to liave li.-ni ii.vsinical. Dmiug
lier stay witli lis this opinion was coiiiiinicd hy the fact tliat iii Ilie
earlier days after lier admission, when >hc was l.iokiii}; somewhat
anxious in the face, she ajiain jjave an e\hil)ilion of p.Tforatiou. SJie
comidaimMl of acute jiain in the .•pi-a>iiiiiiii. the upper ahdomeu
hecame suddenly distended, and llie miiscl<-s appeaie.l teii>e. There
was, however, no dian.e in lier faeial e\piv>Mon ; the jiiiUeiate. or
temiieniture, and oilier symiitoms were not in aunemiiit with peitoia-
tion ; we had also tlic liistory to go ii])on.

This patient left St. Thomas's al.oiit a lorilii-lit after the o)Mialiou
for the varicose veins, Init returned in l!Mi4 on account of haiiiat.iuesis.
She was vomiting daily laigi' .iiiantiiles of liuid. in which theie was a
good deal of hlood of dark I'olour, evenly dilfiised. In ,pite of the fact
thai this conliinied for a month without eessation, she showed no signs
of amemia. and alwa.vs presented a smiling face to I he world. No
particular drug was given to arrest the l.leeding, which was regarded as
of hysterical origin. When tlie luematemesis liad cea>ed lor a'lew days
and .she had hecome hrighl and clieei fill she was seni home.

In ahoiil tliree months' time she was sent hack to tli<> hospital with
another attack of Inematemesis of simiiai- character, from which ^he
recovered in from Ihree to four weeks, aii<l letiirned to her home
quite well.

It was some months liefore anything fiiither was heaul of her, liu(
.slie had not l)een altogether idle. It appeared tlial >hr lia<l again

developed lia'niatemesis when the inllii.'nc f the hospital hail pa>,-ed

olf, and iJiis time lier friends sent her to a hospital ■ where tlieie was a
surgeon who would oiieiaie."

Her next admission to St. Thomas's was on .Inly lit. lito.-,, wli.u she
was fouml to have a fa'cal fistula, which coiiiiiitinieated with the
transverse colon and wa>s situated at the lower part of a sear, through
which, it Was .staled, her siomacli liad heeu operated on. We wt^e
informed hy letter that althougli no ulcer or cau.se for the hainoirha";'

!jm^

I!

2:u

THK ACUTE ABDOMEN'

Wiis found al llic cMuniiialioii. it was iIioukIh liyllif siirj^'iMiii tlial tlioro
wa-t an ulcer in tlip diKHlcimin. slic said Ihataltor tlio oiM-ralion slio
did very well until flic lonlli day, when it wan loiiud that llio milk
which she was takiii); oanic tlirouj;h into her dresHinj,'>i. A nceond
Kltcration was dnjie and the milk no longer came thronj;]! tlio wound,
but in ten days' lime liecal mailer aiipeaied when sht- took medicine,
and ficcal fluid came through if she had an enema adminisiered.

The ahdomcn was ojiened in the middle line helow the old scar and a
lateral anastomosis of the large howel aliove and helow the list ula done.
There were many adhesions. Hecovery from this operation was quite
uneventful, the fistula was allowed to close and, when she left the
hospiial, was about the size of an ordinary wooden match. She left at
her own re(|uest.

Keadmission v , sought .Tanuary. 1!M)(». because she said that the
escape of gas from the fistula was troublesome and caused otTence to
patients when she was nursing them.

There was now a list ula about the size of a cedar pencil, and as the
bowels were acting well there appeared no reason why this rshould not
be permitted to close. Accordingly a dressing was place<l over it, and
secured in position by means of broad strips of rubber strapping. The
fistula closed to some extent, but we could not feel sure that it was not
kept open in some way l)y mechanical means at the command of the
patient. A smaller dressing was then applied, and this wa.s covered
and lield in position by means of collodion. After this was applied she
complained of "excruciating '" pain and said that she could not possibly
bear tlio agony of it. It was not. liowever, removed for a week, when
the fistula liad completely closed. 1 may perliaps mention that the
fistula was found to have become distinctly larger after she had had a
bath without the presence of a nurse : this was before tlie collodion was
applied.

We were for a time under the impression that the case was now
completed, but in March, 1009, she again came into the liospital during
the cleaning of a charitable institution to which she had gained admis-
sion. A ficcal list ula had formed at tlie site of the former one, and she
refused to have auythiiig done with a view to closing it. When ques-
tioned as to the formation of this fistula she said that an abscess had
come and burst, leaving the fistula behind it, but there is a possibility
that it did not form in this manner. If it had been closed, and this
would soon have occurred under simple treatment, for there was a free
normal passage for the fjrces, she would no longer have been eligible
for the institution in which she had now been received.

I may add tiiat lier expression was tluit of a neiirotie, and the
diagnosis of iiysteria was conlinned in many ways.

It Avas .surely unnecessary to perform a gastrotomy for the
relief of ha'matemesi.s in a case with this liistory.

Gardini ' Jias given the account of a case of similar origin.

' ."/•/(/,■<( MiHlfrnn. May. 19ii."> : British MeiUcid Jtmrual, iOpi tome, August, lUo:,.

kiXI<!S^

•l^tK^W-

:-*ltK^

''.iT'MWm

OTHER CAUSKS OF THK AC L TK ABlXLMKX

i'3:

A liitl if 22 had sutr.n.l .n>in tn^triv .sy„.,,t.„u.s f,„ ^jx v..;,m >,,,1
almoHt dully voniitiiii: (it Wood lor liv<- ujoiitL- „r n.oi.."- in'f'hul
insiaiK'*^ tlu! imirouH riifiiil.ran.' ol ihr ^lomacli i.s ^aid to liav,, tn-vn
tinned, hy|M.itro,,1,ic. and of a rod .olour. l.ut ti.ero wa« no .-vidrnt oatiHu
for the hanu.rrliaK.'. '11"' l>alu-nt was appan^ntly .nrrd l.v fh.- opera
tion. (iastric ha-nioirhat'.' has .son...tiuii.s a purdy nnCous origin •
Honietinies it is niinply a form of vicarious nu-uMruaiion and has a
relationship to the nieuHtnial periods, as well as to emotional uid
constitutional disturbances and injury.

It is advisahl.^ to exclude the possibility ol cinho>i.. of the liver as i
possible cause. ' '

^^'^

I

till

I'AIIT Vl
oiJS'iiurrioNs

STn.\\(;iL.\TI(»X (U- THK STOMACH.

This rart' conditioii is only nut with wlicn the >t(iii.:i(li has
tornicd part of a licinial protrusion through the liiaphrajiiii into
the chest. It i> well illn.-tratfil by th' case dcscrihfil, where
the .symptoms were entirelv due to ohstruetion (praetieally
total) of the stomaeh alone. Xothinj; could pas> into it from
the mouth, and the residt was shown in the distress, fre(iuent
voMiitinji. , xcessive thirst, diminished e.vcretion of urine. ia|)id
emaciation and l>oat-slia|)ed alxlomen. 'J'hc stomach was
accompanied in its escape from the ahlomen l)y the tran.>verse
colon, but this was not obviously obstructed. The |)atient was
practically dehydrated, and thcelVcct of saline infusion was such
that operative treatment, althoujjh delayed, was male possil)le.

A fipauianl, ajjcd ,'5o. jdunialisi, •X* ^v;|M ailinitlcil April 15, 19ul.
Up wxs tlion very ill and cinaciiitcd, with sunken eves and liolldw
clici'ks. He ciiiiiplaincd of )iain in I lie uppfr alidoincn : llicrc wa-<
constant vomit inj; oi thin (laid, antl ho had a fiThli' puis 'I'hf
abdomen wa> retracted anil lioat-shaiied ; tlieic was some 1 miu's>
in the epijiastiinm, especially to the lelt of the middle line. < ihii>t

was {;i'eat. (tn aihnission lie was so ill that an inliave .s saline
Holulion to the extent of tlnce joints was driven, lie did noi look as if
he could live throiiKh the nijjht.'

The history of the case was n, follows : — He had in the course of his
profossioual duties in .Spain, as a jonrnuli.st, enco;!nter<'l ^',lc(■es^fully
on some live occasions rivals in the jiolitical world, usiiiji; a i.ipier as his
Weapon. AN'heii he again hail a ilitTeience of opinion, which was refencd
to tlio arhitrament of the swoid, his i)]i|)oni'nt tlimiirht it wiser to
prevent an encounter which wo,ilil very im^sihly have disastrous conse-
quences to himself. lie therefore hired a hravo who took an oi)|M>rt unity
of stalihinf; our ]> ent in the left side with a knife before the date of
the duel. The d>-^ior who treated him for this wound, which was
received about six years before the man came under our I'are. said that
'• lie .saw the lining ol the stomach." After recovery it was three years
before any serious symptoms developed, and he then had an attack of

' /.>inirt, V,,|. II.. |;hi|. \k l.-.sj.

STHANtU'LATIOX oK THR STd.MAlll

■2:r,

vomitiu){, Willi nuvciro paiii in tlit> ir^iou i>i tlif noiiiKl, I'niia whuli <ii<
r'covciKl III 11 lew diiys. lie hail >iiI1iti(1 iiriM>i(iii,illy lioiii iiH.nkt iil
«lin<'ii||ih)ti ill llir Hloiliiirli Mild \ mull 111;.', Iliilii mIiIi'Ii Iii' iiIiI ailti'il H'lii't
hy paMNiiii; hit lintels down In-. iIikmI Ii> iii.ikf hiiii^ill -hk. A wnk
bfloic adiiiiHsioii he ('iii<.<.i'd lioiii I'liiii'i- tn I. upland, and w.i- Mi>l«iilly
Kca-Hick. Till' viiiiiiliii;; had riiiil miii'd and lliiir had liivli I'luiililrlit
I oiiHlipaliou lor >ix da>>i. Wlini M't-ii llin il;i\ allri adiiii«^i(>u Willi
l)r. .Mucktuzii', ihf voiiiiliuK and Ihii^t, riniliuind. he wa> cM-iIrd aiid
rt'Hih'ss, placed his (iii^^fiH in his lliroai to iiiaku hiiiisfll iiioir ^irk, and
askt'd lor a larp* tjiiaiiiily of waii'i lo aid ilir \ omitiiii;, I'hi- hmmui
why he did 1 lii« was lifcailst' he had loiilid I lial in I lie ic^s sovcif al lai ks
ol pain and sirkiu'>s I ho iim' oI I Ik; lintel in ihis way Willi I lie elleei
Iiiiidueed would usually resiill in icliil. The leiii|ieial iiie w.i> nil and
Ihe juiIm' was hardly lielceiiliMe. 'llieie afipeaied lo lie >oiiie luliie>->
undei'liiek^ll lowel rills, lull noduliie^s. the elie^l wa-> Well loiiiied and
tlie ribs showed proiiiineiilly uwinx to the ^leai lo^.-. ol ile>h. There was
it scar oviir llie lell hypoclioiidriiiiii In llu lell ;i miliary line. The note
on percussion was resonant all over iind iln- iueatli >ouiid> iiomial.
'J'liere were a IV:w ciepilalion-, at Ihe hase. The cardiac duliios liej.'an
at the ioiuili ril) and did not cxlend to llu^ 11^)11 JMyoiid llu^ !e|| edj;e
ol the sleinuin. 'I'lio apex heal was in t he till h iiileiro>ial >pace, I inch
inleriial lo the liippli) line. The shuikU were noiinal. I'lic iiiiue was
Kcanly. 'I'lic lonKiic was tairly clean, iiavinj; a slight white coating'. It
was necessary to >;ive another three lunts ol saline luioie we could
operate, aiiii this iniiiroved his pulse.

l»u opening the abdomen through an iiKMsioii lielow the leii costal
inargin, a iiuautily ol collapsed giil was louiul. 'I he doceiidiiig colon
was traced upwards to an oval apcituic in the hit «ide ol the diaiilii;igiii
about 2}, inches in gieale>t diaiueler. The stomach had al-o jia.^ed
through this into the lelt p ••• > and wa^ gradually witlnliawn by
traction on parts as they presented. ?>oiiie ot the tii;n>veise colon and
unielituin were adherent and could not be withdrawn. The .•-toiuaih
was marked by the edge ot the aperture and had evidently been tightly
nijiped.

Notliiiig could be done to repair Ihe diaphragmatic opening ; he was
too ill.

'J'lie ett'ect ot the operation was to relieve Imih pain anil vomiting,
but he still had much thirst. ( tn the Isili ii was iiece>>ary to put o-.
a special nurse, he was so very excitable. J Miiing the day he liei|iieiuly
"practised dying," and during one ot these piaciico he pa>M'd away.
The temperature did not rise to normal at any tiiiu' whilst under
treatment.

At the jiui^t-muiiem examiualion. which wa-^ made by J)r. .1. .1.
Perkins, a large loop ot Iraiisveise colon and onicuium was still in the
left chest and iiiiile irreilucible. 1 here \va^ no sac over the pioliiisioii
but a sjiiirious one had been toiiued by the omeiilnin ; tlii- wa-, how-
ever, very incomiil-.te, but slnil olV the pleural cavity. The lell lung
was inished up and there was pleurisy ou botii sides, chiefly on the left,
and the lower lobe of the ielt lung was solid from septic pneumonia.

■I'.

^'^^m^-rr^^SB^j

'V'

238

HK ACUTK ABDO.MKX

Tli(ri< Wiv li»oalim«l [uMitotiitiH. prolmtilv cuuwil Uy the poMituge of
oixaiii^iiiiH Ihniiinh t .,■ \ til of I li». Htoiiiaiii iU tin |iiiiut wli«n> it ha<l
(•»<ii iii|t|)i'il ftit.r it 't Ml Mil I,,.,., I iU tJK' o|«.mtiofi. I'lif <.|N.rurit,' m

iHciiiiir pun I irii'h |M>stciior to I lit- limit of
lln« lii^iiiiii wii-i 111 iliicri ii'liiiioii to tlin

the ilJaphiuL'iii viis ill ili»
llii> pnicurilial »iM', sn il ii
p)!ricjii'(liii;ii.

.Mr. L.t\vi.,-(l 1 , .

l)llti()!l to tlli: ( I

stomach in tli h r n

tluTfforr the si;; •>, w il
over II iiuinhfiof jir .1
(I) Attacks of ();.■,,,,..,
(■J) Discomfort, p; i > n
tioii and strim^r i
as in a case nmU i li ■ i„

V ho lia> ^'ivm mi iiii|ii)rlaiit contri-

•minds ns that protrusion of the

■ may he complitc or partial, and

iiy. 'I'hc symptoms may he spread

•H froir a sudden strain or injury : —

le to 'h" 'imoiu- in the lift cliest.

iltr meals. (:{) Ohstrui-

.ise descrihed. (4) Tetany,

' I" • Sir Husselj Hevnolds.

A woiiiau of 29, ir vhom
y«ars bufon> deatli 1 .nii icl,iii>

.1 foliowt'il a Utah inflicted sewn
Mio sloiiiacli, trausveivto colon, untl
oiiieiituiii w<'i« foui.d ill a hernial 'veiling tlic nizo of two lUt«. in the
left chest. There \ m no lijfht coiiutn.Mioii.

Til- si^'ns wliiili iire of importance in the dia^'iiosis arc the
f 'llowing ; they a>si.-t very much when present, hut they are
not always present :— (I) Stomach or intestinal noises in the
chest. (iI) Intestinal or stomach peri>tal>is .seen throii^di a
thin chest wall. (D) J)isplacement of the heart to the right.
(4) A sound produced hy the forcing of air trom tiie thoracic
part of the stomach into the abdominal part. Other signs of
less importance are ah.sence of breath .sounds : alterations in
rcsoname : changes in shape and deficient movements of the
chest ; sinking in of the ej)igastric region ; inability to lie on
the opposite .side. .Mr. Knaggs consiilers that in >omi" instances
the strangulation of the stomach may be the result of volvulus
of the stomach or torsion of the >mall omentum. Few cases
have been submitted to operation, but slumld o[)eration be
performed, and the condition of the case give opportunity, it
may be possible to do something with the view of preventing
recurrence of the hernia— (1) by suture; (2) covering the
opening by the livir (Berry) ; (3) ■ anchoring the stoniach
and omentum to the parietes in such a way a.s to prevent other
abdominal contents finding their way into the opening "
(Law ford Knaggs).

' l.dHCrt, Vu!. li., \'M)i. p. :s.-„S

-.'^Wfir''7SHF'

IME.ST1NAL « UiM'HK TloX

:»<»

ix'ri:sii\ \L <>iisri!i( iiMN.

Ill .-.noi-l. riim i>l)>iiii(tic.n- ..t the iiiti-tia<>. I h.isr tli.,iii:lit
II Ih'>I to |.n«<i,I it riniii t|„ clmiril ,1,1.. ,,,,.1 ,,. av,,i,|"a>
iiiucli a- |ii),>il»lc the iiioiv |iinvl\ p.itlinld^i,;,! ,.,iti. Ii i.
Iii.|ic<l that y.»ii limy tiinl nhat i- . ,„.i,tial m tlir (Iiat;iin,|~ ami
s<. !.<• iililf t.. coiic uilli iImm' ra-o allli(a|H|i innii.aiat iv cly
in<'.\|Mrifiic.M| ami |.rilia|., >linH-|iaii.l. .1. It i> at all . \. iit> ..|
tlicjirciiti-t iiii|».rlaiic(!li it vuii sImmiI.I hr al.lr t,, •■ appivrialr •

.1 iMsc mIkm it ,.,,|||rs ii.toiv ynll lul til. Mill, nr lioill a.iii.

iiilcstiiial nloini.tii.ii ivijiiiir^ pr-iiiipl >iii):i,al a-i laiicr i| In-
lite is to III' >a\(il.

'I'lif .iiraiip'iii.nl uhirh appear- li, inr iii,,.| practical i- that

<.t tlu'C.MIip.iratiscilccjIlclKynl th, S a II. r'|> ki,,, N , ,1 , ,|„| |„,.( ,, „)

lis met with ill practice.

A. Acute <)li-.tMlctl(>iis other than ilH ii--ii.>cepl i,,m.

I>. Illtll»ll.-cepti(>ii,

' '. Acute supervening on chronic oli-trintion.
A. Aciile iiitotinal ohstiiiclioii is re>poii-il)l,. In, alu-ut 1'4

per cent, ot all cases of the •• aciM,' aliih ii wilhoiit in, hnl-

inj^ the cases of intus-,ii>ceptioii. which constitute ahinit lii jicr
cent. The oiis.-t of the attack, with the syiiipt,.in- .,f
'• peritonisin"- aliiloiuinal jiaiii. shock ami \oiiiitiii;; mmh
ivseinl.les that in perforaf ion> -if the li,.llou viscera: ami
the same careful e.vaniiiiation of the abd.-sii, n an<l analy,-i> ot
syiiiptoins will he reipiin'd. The character of the pain ■> .,|
little value, hut it is iiiiieh increased hy percii'.>ioii in |ierit,M tis,
more .so than hy paljiation, w liik-t in ohstmctioii jieivi -mu
causes little or no pain, whilst jialpalion is less readily t,>ieraie,i.
'I he voinitinij; is .sevi-re. and changes its ch.iiacicr a- the ca-<-
proj.;resses. hecominji very foul-snielling iatei'. Shock may h.
profound, hut variis greatly. The abdominal wall 'n oh.>tru'-
tion is mobile and soft excepting during a paro.\ysm of pain
whilst in peritonitis it is rigid. I'eristaltic movements ar- m- -v
eonuuonly seen in obstruction, but may be found in ixrit, nitis
when the inllammatiou is localised, as 1 have shown in ca.ses
of perforated simple ulcer of the jejunum. In obstruction
IK'ristaltie waves can freipiently be excited by friition of the
abdominal wall. The bowels are confined, neither lac, ^ nor
llatii.s being paissed.

I'

hki

si

li

240

THE ACUTE ABDOMEN

In tlic scvorcly toxic fonn, or the last stages of pi'ritonitis,
tlic abdoiuinal wall, previously rigid, beeoines soft and pliable
again. As a rule, in the perforations leading to peritonitis the
patient lies (piiet, with (lexed thighs : in obstruction he moves
about in bed, altering his j)osition to that which appears for
the nu)nient to be most comfortable, and complains of almost
intolerable griping i)ain, usually referred to the region of the
und)ilicus. In all a careful search should l)e made for any
abnormal swelling, which in acute ()l)structiou may be found in
various ])arts of the abdomen. As the case progresses, general
distension of the abdonu'ii supervenes and increases, and any
localised swelling will be gradually merged in the general
eidargement. Septic absorjjtion and inflammation arc su])er-
adiled and the case practically becomes one of peritonitis of the
most grave nature. If seen for the (irst time at this stage a
diagnosis of the exact cause of the inflammation is impossible.
but prompt measures may yet prevent a fatal termination.
Luckily patients do not often permit things to progress to this
extent before applying for relii-f .

In tliose cases in which obstruction is not so acute in its
onset you not infre([uently find, before it becomes complete,
complaint!* of griping pain and can see and feel local hardening
and swelling of the abdominal wall, with gurgling as gas is
forced past the obstruction.

An example of one of the most easily diagnosed (and
remedied) forms of obstruction, both from its nature and the
short time which elapsed before operation, may be given.

A marrii'd woiimu of 38 was admitted April 15, 1914, with a history
that on the previon.s evening she had lelt some sloiiuu'h-acho, but it was
not bad until she had jrone to ))ed. It then became very seveie and slir
had troublesome vomiting all night. At tlie time of operation (1.30 p.m.)
she was still sutieriug from pain and wa-s vomiting at intervals, the iiuiii
was paroxysmal and situated in the lower abdomen. The abdonuMi
was somewhat distended, with sliifting dulness in tlie flanks ; the pain
wa.s referred to the under sinface of the lower end of the left rectus.
i^onw of the coils of small intestine were very clearly outlined, and there
was occasional peristaltic movement. Nothing abnormal was f'tlt on
vaginal examination. J^lic had never had any previous illness. Al-
together the evidence appeared to be in favour of volvulus of small
intestine as a cause for the obstruction, although there was no tumoiii.

The right rectus was displaced outwards, and when the af)domen was
opened a large quautily ol clear fluid escaped. The smail iutedtine wa-!

' i:

INTESTIXAL ( )B.STrUTTI( ).\

-Ml

gonerally d..te.i.l,Ml au.l tl„. h,>-. ,t ....il ,,;,.„.,l i„,„ ,|,e „dv .
wh.ehacontract,..lil..u„M.Mi.T-r,l. At t|„. imim wlmv il„<' „,.■.
- fi-et from the il...,.,.„val valvo, tlio dilat.-.l b,.w-l was iwiM."
.>vt.rla!ti)nijf ilio coiitraclc.l i.oiiiou fioin l,.tt i„ ij.^i,, \\-|„,„
to Iho siulac.., )h., nul of tho (tilaUMl bow.'l frit hi^.vv aii.l .„,.
some irnrular pavticl..s of u.i.lii:,.>i,..l f.,o,l. |„ vi-w' of tl„. ,i,.
ot I-.a^torMou.Liy.it was suir-.-,!,.,! l>y onf of tl„. .I.v.mm- ih.r |,i.
be pan ol an im.Ii^.sh.d roroa-ruit. 'rii,> .•oi,t...u. of li,,. l,„u,.
easily parsed on, mikI llio ololniclioii was ivli,.v.Ml willioiii ;nn -
mampulatiou. The wound was siuuicd in lav.rs ,,nd il„- imii.-ui I

, from
alioiit
d and

1 1 lawn
Uunrd
aini'-s

llliu'lll.

I Were
pccial
il had

l-|ii. :il. — I'.iiil-Iu-Kicl Aiiii>^l()miiHii ,it'f,r A'/vm/../,. -- ( ili|j,ji|,> Sorti ;ii .,1
llowcl aft.T iii^iilicatioii of (,'l:iiiii.> : I. Small iiitfstinc •_'. Clamp--.
.'i. OblKiiie section of dowel. I. Cut mesi'iiterv comin..' well hrvond
eii;:i. of section. ,->. WedfTcliaiied removal ilf me-cntoiv of limited
extent. The |ioint~ of the clamps should he iienivr to the ( ut e l.'e of
the mesentery.

an uninlerruplod couvah-seeiue. I'ortions of cooua-iuit were pa.-sed
ivitli the first action of the bowels.

TIk- obstruction was not coinplftc, tlicreforc tliciv was an
fxuilafion of fnv liuid into the [HTitonctiin. No localised
i^wcliing could be felt, partly because tlie twist wa.-< in the
pelvis, and llie coil affected was not distendcl witli nuicli ga.s.
Karly o})eration was all that was rc«iuiri'd to put ihinjrs rij.'ht.

As ;in example of volvulus producing a more severe form of
obstruction in which early operation is most desirable tho
following ease may be given: —

A.A. n

-■{ i «

III

I* -

242

THE ACITK ABDOMEN

:-:-? -4

«.. D.. a«(Ml 2S. was admitt.-.l ^ „„ XowinLor 7, l!t04. with acute
intcsliuul ..l.st.ucti..u. At 4 ,..,u. ou ih,- day WUno aainis.si„u J,o was
su,l.l,.nly seized with pain in the low..,- al.donn.ii ; siuco that time his
t).)wels had not hecii ..[.Piicd. m-hlwr had h<. jm^sed fhidis 'J'hcrc liid
hvi'u vinil inj; off and on sine.. 1 h.. ..ns..| . The pain ha.l heen continuous
in eharaeter, with paioxysms On a.lmission it was sfate.l • " 'J'he
pat LMU's face is drawn with i.ain, he e.)nlinually moans an.l pants
Ho complains of pain in the al.dom.'u, which do.vs not m.)ve at all in
Its lower part diinn;,' inspiration, an.l in..vcm.Mit is jx.or in tli.. upiu.r
part There IS a marked pr.Mnin..n.... in the hyjiogastri.. region in tlu
middle hnc, l.mkmg like a niweh .list..nd..,l l.lad.ler. Tho percussion

not., ov.'rthis area is resonant and
tli.^ jiail very ten.ler. The liver
diiliK.ss is not diminished and the
ali.lonieu appears to hv normal in
other i)arts."' The jmlse was Il'k
and th.. temp(.ratiiie was Jooc; .
CatliettMisni did n.it diminis!> tli<.
size of the svv(.llini;. When se.'ii
withJ)r. C. H. B.>x, under wh.>s..
car.' the man had hecn admitt<.d,
the local signs had he..ome less
aciiti- and there was less complaint
of pain. Acute intestinal ohsduc-
fion was diagnosed, due to vol-
vulus of small intestine, or
.strangulati.)u i^ a band. Tli..
patient was a strong, heallhv-
looking man, without any histoiy
of previous attacks of abdominal
pain.

At 0.45 the abdom..n was open.'d
below the umbili<.us to the right
of the mi.l.lle line. th.. r.>ctus l)(.?!ig
displaced outwards. "When the
p..iit.)neum was incised a very
. , ,, . hhifk ..oil of small intestine i>re-

«ented ; tins was v..iy t.-ns,. an.l har.l an.l coul.l not be drawn up thron^h
the wound t was theref.ue ,H,nct,ir,.d with a tr.ichar. and a .,uantiu-
of flui.l whi.h consisted almost entiivly of venous bh.od, escap.'d ■ this
had a imcal ...lour This coil was th.-n bn.ught oufsi.lo ami foin'id to
be th.. Ileum immediately bef..re its juncti.m with th,. ca.cum. Another
coil then present,..! itself and was also tap,H..l an.l emptied .,f simiia,
fluid contents ami flatiKs: it was now possible to lift the whole ..f the
affected gitt out of the abdomen. This was quite black, and when
emptied of its ..ontents without resiliency, although th,. peritoneal
covering was not without polish. The twist which had occurred was
one on the mesenteric axis from right to left, but when this had been
reduced no improvement occurred in the circulation of the affected

.■■ a« J»

of !<mnU Jiif(i>lin(.— 'nw inner
suture conii)leteil. I. The nuter
suture eoiitinued. '2. On com-
pletion it will be tied Ut ;i. which
is the same tlireud left long for
this purpose. 4. Sutures dosing
mesenterv.

^:^^^jmi''-%''l^WWXi

I XT EST I X.\ I, ( I J >sT nVi T I ( > X

1M.{

m<"s,.n...,y liu.U.uv.l alt..,- tl,.. n.pi.l ,n.Mli. , , 1 u " "

vm left .t il„. il.. '"\"""- . "'"■ i'i.|Mr ,.,m1 ua. lli,,, \,„u,a i„ ,|„.

aunn:;:- i i':i::!:r;:r':"''^ '•"■•-

•";":"'' .•i^n-''-^''-ii;ir!;:::; ::':n:,:i::ii;;,^

-'.■Iv.s .•outa.nnl .lark l.l.m,l-Man...,l oIVwimv.. In 11

y.ni.h ,.,VMM,t ou auv par. ol , h. p..nl..„ ., , , , , ?'^ ""

.he ..,..n.n..u wi,h s,..nii..a s!.,iu.. .:'hn ; .' w. :, ';;'r :.',""";'■'' :

deep and suiMMlirialsut Mies. r|,|,„„|o, „, u- . i " ■'; 'I'-'d will.

;"<• "p-'i-u .wo i„,i....n...s ... .:!,;:;:;;;;,;;';;:;:;::;;,::'•' """-

li,V|>... .(irti callv iiii.l lit..]- I-..., ,.i "'""'">' "III"'' "ii'v-n..,,

..,!';s;i;f;=.:i-;;i::--:;;r:is,-;:r;;-;;;:,:,;,--
;;[r™;.:'»'i-r,T:;::-r::;:L;;;';:-;:-:, '-^

a''«lom,ual wall wi.h„u, luMuial pn.,n,si,;u was M.,:!^' """'

uth .t \u uuxny l,our< |...| ,.|a,.M.,| si,,,... ,|„. o„M.t ,.t

Imk.ly ,t ha,l not giv,... nay into th. ..urr.\ p,.,.i,o,u.al ,..vi,v'
l)r ( L (.,l,sn„. ot .\,.w Vo,.|<. ,.,.||eH,.,| I „.„, ,,,.,.. i,,'
".tosfnal ol,s,nu.ti„., (i„..Iu,li„. ,M .a^.s .,f M,.a,„M,lat,.,
lu'nua), an.l aniongst tLcs. tl„ ,•,. „,.,•.. li'l „,>,.. ,.t v.^lv,,!,,.

nu.Iud..,! tl.os.. alh.,.t.n. tl... lar,.. i,.„.s,i„.,, „,„,,, ,,,, ,,, ,- „. „„,
..lost c..,nm.,„ ,.,mstit,.ti,.. p,.a..,i..ally „„. „„|v ,„,,„ ■„, ,,„„,
obstrucumottl... Ia,.„. 1,....,. This va.i,., v „f ..hst,.,,.., „
wi^u .^..tm, tl... la,-,.. i,,,,.n,H. l,as a ,.,.,;...,,u- ..,■ ,^

;*/ 7f- "'■^'•^^"•'•""•'t-lto,.I,y,|,,,a,, ,|,a, ,l,...i,.all
gut IS .,t tar great..,. i,np.„.,a„c.... ul.ilst .1... v i.alitv of its walls
IS probably ioss. Wlu-,. tl.,- s,,,, 11 i,,,,.,„... ,.„;..,„,,;.,., ''f
volvulus the. sy„.pto,„s a,'.. ,.i.,n. a..,,!,.. ,..a,.if..stati..,.. ..f sl,„,|<
arc; more ,„ark,.,:, an,| possibly its ,„ol.i|i,v allows of a t,.r|.t..r

tw.st. Kn,nv,ng 1 1... ten.l..n..y tlKTe is !o pMhli.h .„lv Mi.-,-.:,sf„l
oases, It ,,s very probable that Dr. Gibson's statisti.'s a,v nm.,-

' Se.. Kj.r. 31'.

K2

244

THE ACTTE ABlXhMEN

favour.ihic than tlicy sIkiuIiI \n\ He t'ouinl only titic rccnr.l
(if siicH'ssful ri'ficctidii for jj;aii<rrciic due to volvulus of small
int'-sti'ic. and this was pcrfonncil by Hii'dt'l on the secoiid dav
of cbst rial ion.

A soincwliut similar clinical picture is pn.-cntcd hy oljstriic-
tion by .Mcokd's diverticulum, the symptoms of which are
jiractically those produced l)y any kind of l)and. There is
less freijuently a history to jiuide you as to the actual cause of
the ol)struetion in these cases : no aci-ount heini' triven of a
previous inflammatory attack or of injury, althou^di you mav

111

I'lii. ■'!:>. ()l)>truit ion jiiiiiliupd by ^^('l•kt'l'> iMvcrtiiuluiii, .\.
(St. Tlidiiias's llusiiitiil Muscuiii.)

mm

at tinu's hear of occasional " stomiich-aches."' (iibsoii uives
42 I'uscs of obstruction 1)y Meckel's diverticulum, as aijainst
18() by ))ands of various other kinds. This seems to me to be
much too high a proportion as compared with actual ]iractice ;
obstruction due to a Meckel's diverticulum is not often .seen
in our hospitals.

The symj)toms produced by the compression of small intes-
tine by a band are practically the same as those described when
the cause is a twist — viz., " peritoni.sni " — with the formation of
a localised swelling in the lower abdomen, which i.s resonant on
percussion, Any swelling of this kind should be regarded as of
importance and as an indication that nothing but operative

*<:'. '^TBIKSW?l-fr-jjj;«B:»5^"' ^^S: HB^HHSK

INTESTINAL ()HSTIU( TION

24.-,

tm.tnu.Mt !s ,..,ssih|,.. Th.. ni.,„l> mm.m l,,- at .„„•,. ,n.,,n,u.,|
">t tl"s: thvy will pn.l.ai.ly prutx ,,„ 1 (!„■ palimt ,l,,,„.r.l
nmrplnuc for the ivli.-f -t iH> pain, hut v-m „n.~t !..• .in,,

It w most M.iporlant that al.l i.ul np.n.linn^ >l,nMl.l hr

Pf't-nm.,! lu.foiv any -•■ncral .list,.n>iun mI. in ,,p,.,a,i„„ i.
tar mon- diflicull in tlu- tar., ot ,lisi,,,Mnn. uj,,!., ,h.. ,,.„|, ;,
likely to l)c nnuli less satisfactorv.

In a stout man of 4(i u ho l.a l" >tran._'uiatinn of ,r„t I,,- ,|,is
.livrtK^ulnm I fo,m.i it n(.rrs>a:y to rx.,'.,. som.. 4.i in.i„s of
thf small bowel. },nt ti.e >titel,.-s ^av.. wav, iMcauM. I prnl,al,lv
plaee.l ti.em in dania-,.;! l,ow;-l. It is po<sil,|,. that a ui,|,"r
removal ot the jianiireiious yut would have hal a liettcr result
for I lost my ))atieiit.

In l).)tli the.se ea.scs of iraiiL'ren.' the progress ,,f .vents \Nas
rapid, the gut havinu l)eeome .ramrrenous in a few hours from the
onset of sympt(mis. !„ .hvling uifh volvulus it is only nrccs.
sary to empty the involved intestine, an I after dra'win.' it
from the ab.lomen twist it round in the re.piired .lireefion
In diverticulum. aft.T the l.a.ul has 1„m„ found (not alway, „
easy thing, if one may judge l,y reeordrd ca.M.s). it r.^iuirrs t,
be divided and the ends afterwar.ls .Icalt with. Let me ivnin.,
you of the necessity of examining carefuilv .inv haml that may
be divided during the proir,vss of an opnati'on for int.-tl.,,',!
obstructum. 1 bave known the careless .livision of a Mrck.'l s
diverticulum to allow of the escape of intestinaf .ontents ,nto
the peritoneal cavity, which occurrence resulted m a lapidlv
latal peritonitis.

In these cases \vc were met by a very f,,rn,i(labl.. cninpjica-
tion which requires special consideration. .\|,,rc .,r hss ..xten-
sive gangrene of the intestine may confn, ,t v,ai in anv acute
abdominal ca.sc in which operation is ju'iforini I. and v<ui must
be able to deal with it on the spot. It is of vital importance
that the safe pa.s.sage (,f the intestinal conl.'nt^ aloim the cuial
should be made p().ssi!)|,.. There will h.. no time to s,,, I a
hurried messenger for button, bobbin, special forceps, or any
• me ^f the .scores of suggested mechanical aids on uliicl, vo'u
ma\ hiae dccidc.l to pin your faith ; in tli.^ presence of this
complication you must imniediatelv act. if vou uish to save
the life of the patient. The faith uhirh wa> fornu i U piare.l
in the special iu.strument sliould be put in an accurate" method

o

fiit

Mil

i!ii

m

24«)

THK Ad'TI-: AUDOMKX

1)1 MiluriiiL'. at'lcru jii lici(Hi> >"lccti()n of the pniuls of >ccli((ii
of the ^'iif . and in tlic |)nTaiili(ni> afiainst >c|i>i>. w liicli arc now
a pari of the nsnal ((■{■lnii(|Uc.

'I'lu'if air many cax's of localised >.'an^'i'cnc in w lii<li it i>
found tliat a part of the ;.'ut doe- not look >oun('. lint of
wliicli it is not possible to .-ay that it will not recover if placed
in favoiii-al)le eircnni-lanee-. W'lien tlie portion of bowel
atfeeted is very iocalisid. as when the pre— lire of a hand
has produced a ti;ni-\( ise lesion, it may lie po.-sihie to invert
this 1)\- a row of Lendtert sutures, a- suiijicsteil l)y Professor
Caird. I have ('one this with satiNfactory results in early
eases of stranuulatcd hernia and pre--ure hy hand.

'I'lie trcatnu'Ut of (.'anjirene of the small intestine when the
entire circumference is affected will depend (»n tlie i;eneral
condition of the patient, and the circumstances of the case,
rather than (Hi the extent of the jian^rene. for tlii' procedure
will he muci\ ' ■ ,-ame whether you resect I inch or I vard.
In favouralde circinn-tances excision should he the method
adoj)ted in the case of uau^renous intestine. Delivery of the
alTected part from the abdominal ca\ity. exaniination to define
the extent, not oidy ;:ani;renous but chaiiiicd beyond tlii-.
cleansinj,' of the part, careful jiackirif.' off of the hi'altiiy area
with .-lerilised trauze, covering <'f the j^'anjircnous part with
^au/e to prevent po-sibic contaniiuation of the wound,
resection, and subseipient joining of the eni!-.

In the resection of the jiut in ))oth eases which 1 ha\c re corded
Doyen's elanijis were used and answered their purpose well.
J usi'd them because they were handy. In other casi'> ol
resection pieces of drainauc tuJ)e passed tlirouirh the mesentery
and .secured by tyin^' or by forcejis have answered e(]ually well.
Stri])s of uau/.e weuld answer in e'a-e' you hael ne) eirainajre' tube'
available'. The' ))re)ximal anel elistal clamj)- should be place'd
i' iiU'lu's abe)ve' or be'low the line eif |)re)pose'd se etion in a lie'althy
jiart. 1 lay very >peeial stre-- uu \\n> peiint. bee'ause' in the
case' e)f eifjstrue'tieni by a -Mee-Kcls eiivefticulum it appe'areel
that tile' suturiiiL' faile'el because' the' .stitches ceiulel iie)t lieilel
in tissue \\hieh liael been stretelieel anel whicli unelcrwent
afte'T-wareis an intlaiiimateiry reactietn anel softening;. The-
bowel seemeel liealthy. anel one was naturally ne)t aiixie)U>
tu exeic>e more than was iictcosurv. It is often advisabk to

"M^-, i1^'~,'i.'W»"<r',

IXTKSTl XAL ( )BSTH( •( TIOX

'\:

cut the huwfl a lonjr (li^iniicc away ; tur iii>taiicc. in .laimaiv
l!Ht."». i n-scctrd Id iiiclus of small infcstinc with jiood loiilt
ill a car-t' of >tiaiii.'ulatcil tciiioral licriiia. alllioiiyli the part
alTictcd l»y jiaiim-ciic was only alioiii I inch in IciiL'th. 'I'lic
howcl close to this was not in a healthy slate. As each end
of the howel is se|)arat/d it should lie cleaned and wra|»|)ed in
^aii/.c until wanted. One or two vessels mav re(|iiire li<;ature.
^'ou nee I not e.xei.se a wed^ie-sliapcd iKirtion of tiie niescntery,
i'.s in the removal of a new L'rowth of the howel (see Fiu'. 'i2).

The jiinetion of the two ends should he nia le l>y careful
suturiiii.' with a dotihle row of silk sutiiivs. These should l»e
continuou.s. for they are more rapidly applied than the inter-
rupted, and are e(|ually elficicnt. Aceor.linj.' to the thicUness
of the intestinal wall should he the size of the suture material.
As a ruK'. No. I is ri<;ht for the adult. The first should include
all the coats of the howcl ; th.- second will take only the two
outer, as a rule. In applyiii;.' this, you must see that the
suture has a i£<iod hold. If you aro satisfied on this point, it is
not advisahh' to dip the needle iiion' dee|)ly. for if you pass your
outer thri'iid into the I'liuen of the howcl. in the endeavour
to get a stronger hold, yo.'r patient will probalily do badly.
When applying the deeper stiteh hold the two porti(»ns of howcl
with forceps, one pair applied at the mesenteric point of attach-
ment of each half, the other to a corresponding jioint opposite.
If a pair of foreep.s is also placed lialf-w ay between these, closely
applying the cut edges, the suture can be introduced .■^till more
ra|)idly. The iiu S;'nterv should then be sutured, so as to presi'iit
no raw surface to which adhesions can form . the part-« involved
in the operation aie cleansed, and the abdominal wound closed
without drainage.

The amount of inti-stine resected in these easi's aj)pears
large ; 43 inches in one ca.se. and 4t'> inches in the other. Hut
greater lengths have heen e.\ci.-ed. .Mr. .\. K. .1. Marker,
in a verj' instructive ])aper on the limitations of enterectomy,
mentions a case in which .Mr. Hayes, of J)ubliii, successfully
excised 8 feet il inches of int»'stine foi' injury in a hoy aged 10
years. A"other paper by Mv. J5arker will repay perusal. It
is on enterectomy for gangrenous hernia. Many practical
points are brought out. He also shows that the amount of
shock is Jiiuch less than is believed from such an e\ieiisi\e

^fT

"W

:i8

THE ACUTE ABDOMEX

liill

'}

li i

ojxTutiun. I have mcntionod thoso cxnisicns of lar«c pieces
of infest. ne in sh„u- „hat ean be done, so that you may n<.t
In' Uitihu.late.l slioul.l you meet vvitli one of these extreme
cuses remeinhering that if the gut at the point of union is
.s<Mm.l, and you take proper precautions iti following the various
steps of the op<-ration, you may gain a success, even in desperate
on-(iimstanees.

The effect on the patient of the removal of a hirge portion
of the small mtestme is apparently very slight. In the former
of the two eases of which I have just given .letails, then' was,
lor a time, a tendency to looseness of the bowels; but this
pa>sed on. and h.- n-gained good health, ex-.^epting for occasional
nid.g.sf.r.u.- The effect on the intestine has been recorde.l
hy .Mr. J^arker in two ca.ses in which he ha.l an opportunity
<;f lookn.g at the bowel during life .some months (in .me case
hve years) after operation. In both, the line of union was
sound and without contracti.m. but the bowel on the proximal
side was somewhat larger than that on the .listal side, and
showed smaller power of muscular contraction.

In the cases of volvulus the probable cause and position of
the obstruction was known and the incision was made to give
most direct access to it, due regard being paid to the anatomical
nrrangement of the muscles of the abdominal wall.

\\hat is the best incision to use in cases where the cause
of an acute obstruction is unknown, and what steps should be
undertaken to find and remedy this when it is found ?

1 think that an inci.sion through the right rectus sheath to
the inner .side with displacement of mu.scle outwards is the
best ; It should be of a size large enough to admit the hand
far too much time is lost in making a small incision an.l then
enlarging it : you may make a small opening through the
peritoneum at first, for it may be possible to (piicklv discover
the cause of the symptoms. Anyway an extension of the
ncision in the peritoneum is very quickly effected. I have
already pointed out the importance of operating before the
oiLset of distension ; where the bowel is but slightly distended
manipulation within the abdomen is easy, for the hand vav
be passed from point to point without dihiculty.

Where the small intestines are <.bstructed you should first
examine the ilcu-ci.oal region, and if there is empty gut there

INTESTLN'AL OBSTIircTlOX

2ll»

foll'jw it upwiinis til till' ol)>tnictinii ; Itiil il i- l.ttirr tn i'm|»ty
ilistt'ivli'il <<iil id iiiMiv than niir point \\\u\i ilniv i> nimli
flistcnsioii iMtlicr tliau aiM to tlic ilan.'ir (.f the cax' liv linii>iiiu
witli your hand tln' alrciily daniau'cil wall ol tlir u'lit . Tin-
not only cnahlcs yon to <x|tlnrc the ah lomi'n with L'lvalci
rapidity and snrfncss, hut j^cts rid ot a Luv't- ainoinil ut toxic
material, the absorption of which adds niiuh to the dangers
which the patient is t'acini.'. A loop of unt .-liiadd he drawn
out, placed over a sterilised ve-.-el. and pnnitnnd oppo>ite
the mesentery with the point of a knife : it is not needful
that the openin;i; he of lar<_'e >i/e. It is closed hy means of
a Lemhert suture of silk (continuou.-). or hy a piirM->trini;
stitch. The >urface of the howcl is cleansed and the loop
returned, it can be repeated with other coils. In examininti
the ah lonunal contents with the hand, search should he made
for bands, which may he of various kinds, and tlioe >houlil In-
traced to their attachment.- if pos>ihle and cut .-liort : if there
are adhesions which are too .-tmnu to he separatei' it will he
neces.sary to resect the bowel, do a .-hort eircuitinif operation,
or ill a Dad ease open the bowel above after attachiiiL; it to the
abdominal wall (enterostomy).

The operation of enterostomy must he ri'^iardcd as a \i-iv
unsatisfactory opei'at ion unless peifoirued as a piirel\ tempmarv
measure for the relief of disten>ion in advanced oh>t rmtioii of
the bowel or paralytic ileus, it i> -onitt lines po»ihle to save a
lifi' by this proi'cdure when an injudieiou>ly prolmiued operation
would ca.\ise a fatal endinjr. A local ana'stlietie is reipiircd,
and the openinj^ should he made in the ri^ht iliac rei.'ion. the
c;eoum or some presentim; coil of -mall b(A\el heiiii; s( lected
for the insertion of the tube. In an adult of ordinary size the
iiuMsion should i)e about ."> iiulies in leniith. The part of the
bowel to be ojxiied is biouuht to the inei.-ion and sutured there
by means of >i!k suturi's placed in >ueli a |)osition that it will
he possible to put a tube in the centre of the area hroiiuht up.
A small sized l'aul"s tube, or failing' that a piece of lubber
tubinii with sidi' openings nea?' liie extremity, or a .laci|ues
catheter, will answer. A small ti-liL:uf -uture .-hould he passed
throuiih all the structures ot tln' ahdoiiiinal wall at the upper
end of the wound, takiim up the peritoneal and mu-i iilar layeis
of the bowel av.i!!. Another should he passid in a similar

■ I

200

THK A( TTK ABDO.MKX

m

niiuiiur Im'K.w. OHht sutun-s. of silk, slioiil.l tlun Im- passoil
on ffuli sidf to lix tlu- iH'ritnticimi aii<l fasciii (tf the ali(|<itiiiiial
wall to the pi'iitotii'iiiii uiul nmscnlar layers of the intisliiic.
It i.s ati adv(iiitiiK«' to the jjatifiit to liavi- the luhc put in at
one,', ami to facilitate this the loop should he pulled fonvard,
parked olT with j:auze. and the howel ])artly emptied with a
trochar and eanula. 'I'wo pairs of foieej s plaeed one al>o\c
and th" other helow the puneture will hold the jiut in position
whilst an assistant compresses it hehind to prevent further
escape of content^. A purse strint' suture is then placed ro\nid
the openinj; at a. convenient distance and the tuhe inserltd
thnjujjh the cidarued puncture and seeutcd hy tlu' suture.
The howel and wound an- washed with sterilised saline, and
the howel now fixed to the abdominal wall with the silk sutures,
the parts again cleansed, a packing of thin gau/e jjlaccd loinid
the junction, and the free end of the tuhe hrought thnuigh the
dressings and put info a hotth'. To the Pauls tui.e there is a
wider and thinner lu))e already attached. The tuhe comes
away in about four to five days. After this the discharge
escapes on the skin, which rapidly beeomes very excoriated
and painful. Much may be done to mitigate the exceeding
discomfort of this by clean'- less and the ai)plication of oint-
ments. The use of a solution of rubber maybe useful, it should
be painted on after the skin ha.s been cleansed and dried.

From the amount of misery which such an ojuiiing may
eatise. and the tendency to rapid emaciation exhibited, if there
is reason to suspect that the fistula must become permanent
uidess somi'thing more is done, the earliest opjiortunity must
betaken to explore the abdomen and dowiiat the individual
ca.se may recpiire to restore the natural channel.

Another reason in favour of early operation for the re-
establishment of the iu)rmal track is the tendency to the
formation of iliac adhesioi..^ vhich such cases show.

Strangulation by bands i.s one of the most common of the
various forms of acute obstruction, and in its nuiin feature.>
differs very little from obstruction due to a volvulus. ] will
simply give cases which speak for themselves (see Fig. 1).

Intestinal OiisTnrcTiox dik to a BAsn.— On October 5, 1911,
r. P., u single woman, aged 75, woa admitted. -Jf Slie was an old woman
with sunken eheeks, and was lying propped up in bed turnpla:nins <>i

m-

&

n

4 1

INTKSTINAl, (U5STIM ' llnN o-.i

miuh |iiiiii la llii' alxloiiii'U uIjk li Ii.kI ruiiiliii'iiriil .11 1. |trii, llir |>i.M..ii-,
ihiy. Tlii-. pain had l..rii vny ... vnr. U4 n.ial I liioiiyliniii ilit- alMlotnrii,
liiil f\l<inliii« iiikIi'i llif iil» <iit Ixiili »iili> ami -lii.i.tiii:; ilinuiyh io llic
shoiil.liT lilail.-. She liail li.<ii M.riiiliiin all inL'lii autl lii.- im)iiiiii«
111 a(lllii.!4i<ili liirciiii;;li railic iili aiul ('iililllllli'il al l|ii|Ui|it iuu-iViiU.
i'lic IhimcIs, iiftci liiiviiii.' li.-.>ri loiivijiialrd li.i tmn m. Il\f liay*. ai-l. .1
till' moiiiiiu; liflcn.' itilitiis:«iiiii. TJir alHliiniri) \\a- \\.|| (.•ovcinl, lav,
iiKiviii;; fairly well; no <li»IfU-.i(iii. no aluioiiiial <liii)ii-.« ; uotutiiom.
I'llfli! was K'Udfirii^s ciii.lly aliovr llir iiiiil.ilKii,. I, \ulllilll.!iou ;.♦.
niiiniiiiii ^liowi'il iiolliiiii: aliiioirnal. 'i Viii|»ianni'. ds : ]>»]>>'. ItJ.

'I'lifif \\a.> II" lii>loiy ol any [inMoiis illni««.

Oprralion.t; pni. 'riiinwa. a laruf anioiiii' ol l.looil -taintil tliml in
III.' p.iiion.nin. Inn n.i >p,,u ol lal nfcn.-iN w.iv vi-ibl.t anywhfi.'.
alllmiiKl'. till' linid «n«utsl(d tiif |>os<il.iliiy o| acnic pain'rcaiiti-i.
When the jicivis was lAaniincd u twi-llinK lik.' a lop i-onlil be till oti tli.>
ii.'iit side, wiii.'li on Inllcr rxaniinalion lo.nililiil a miIvuIiis. A mtv
nrni hand .-iosmmI iliis, ninniiii,' Imiii ili.- IiukIih id a .itril." uicin> lo
III.' po-tciior pari of ihc p.lvi* 'I'lii-. wa- divld.il with s.'i.>oi>i. ■||i..
Miiall ;,'nl allVcIrd wa.'. 2 Ircl in Ifn^lli, licniniiinu- IH inches lioin I h.'
il('o-(';i'i'al valve. It wa- of very dai k .■..lour, liui loilicnt. ami ^l.i.»>v.
.\diaina«c Uihc w:i.s inscilcd and niMih llnid .liaiiud away l.n lour d.iys,
allcr wiiich it was icniovcd. '1 h. le was nolhiiij: lo >how lio\v iln-
hand ori^'inated.

Tlic a^i' of fliis palii'iit did not |ii(Vfiil licr rccovci v Tlif
i|m'stioii of rccovi I'v <li'|»i ii I- inofc ii|Min tlic staoc of iln-
illin-ss tliiiii ii|H)ii tlic a^"' <d tii'' patient.

ImKSTISM, OllMKl , r|u\ ll\ Al>IU.s|.iNS (Ih.' Il'^ll|l III <i|d p.lvic
disease whii'li had hei ii Uealed by operation, :i iiioh' eoiiiiiiiin iv[m').
S\. M., a iiiairied woman, aueil IM, w.is ail: liltiil Oil.diei ."il. I'.dl."^
Willi an illness of two days' dm. it ion.

She underwent an operation fm doiilili' pMi-^al|)in\ in .laiiiiaiy. and
remaiiieil well afterwards until ih" 2!»l li wii.'i a siidil.n pain v\as l.li

in the epigastrium. This eai li .soon afler Hi and was very seMii'.

She vomited an hour later anil liad done so olien >in<'e. Thi! pain had
remained eoiistant in the ^aine ))la''i'. The bowels aeied on the :!iiih.

The patient .\ is jiale and ivid.'nlly siilVeiinj: severe jiain. I'lil-.' I;i(> ;
respirations, :',l' ; l<'ni|>eraliire. !i.s(i . The abdomen, wlinli w.i- well
covered, moved poorly on rcspiralion: rather di-ieiidiil ; no vi.>ible
IMi i>lalsis ; lymjianitic all over, .\bdoininal wall ~oli and Ihniiil
exc.'jitini; 'I the epiiiastiic rci;ion, wheie there w,i> .'~lij;lit iij,'idil>. and
lier<' she wa> very leniler on palpation. The scar of former operalioii
was visible in thi' tnid-line below the nniliiliciis. The vomited iiialciial
was bile-stained.

At the o]i<'ration a coil of small inte>tine bcn.'alh the incision was
adherent to the alxloii iial wall and In .iiiollicr coil A laiye .-.ection ol
it was empty and coilapM'd. Th.' distended coils were emptied by
puncture and the obstiuclmg adhusious divided. Ih'.- .surtaco of th«

■?!«■

^

^'^^

< i

'■'- THK ACTTE AP.DoMKN

p.. was i,„U,..,-l. Th.-r« wa. „.... ,|uhI ,„ ,1,. ,,..|v„ whi.t. „ .,

• h. «.M,..l ..u„...,|. !,ul (ho.,, wa. .... .,,1..., .•.M„,,|i,,.,,ou. ''''"""""" '"

Ail tl... iHTMi;.! a|.nhuv> „,u>t !..• . .xa.niM..,! lK-f.„v „,«.ra(i.m
.>|HT.allytlMh.m..n.l.i„>,„utw.„n..n I l.av- mivmIJ „,M.n,.,..l
tnr ..l,>,ru.f,..,. .„ luo i„>tam...> ,.» this turn. ..t'h.nmi Tl...
I'al.n.t> .i,.| ,„.,.,,,,],. „,|l: ^.ill I ,„„|,| ,,„, |,,,„„,. ^

-r n„,„.rt..<., ..xa,ninati.m. h is ,..., v.ry ..nux.al t..',i,„l
•l.at .I.J...,. ..xanunati.,,. .,f tl... ....t,,,,. has n.,| h.,.,, ,.am...l

"" : tl... sh....l.l aluays Ih- ,|,„... .|„it.. ,.a.ly. »..,• v.iv vahial,!,.

'"•Ij' >uay Im. air..r.l..,l |,y it^a r. rial j;n.«th ul.i.h wa-- ..„.„.-
P"-««'«l ^i-^ It Kav.- „.. sy.n|)l..,...s : a l,all.,.,n...l .-...■tu... • u,
n.l..sMiM.,.,,t.,„. ..r >;al|-st.m.. i„ tl..- s,„a|| intrsli,... ' a.,
"''P<'«»««1 l.y.lati.l. .„• son... .,lh..r jrn.wth i.. tl... ,,,.|vi.s'- •„,

m ht„u,...tt..ry .^u-\\\n^ al,,.„t ai, ap,H.n.lix. .,i' a s.-ppunuiny

uh... lHs„r«,.,M.h.M.l.lr.....xa,.,iml.M...nlin,.a„vstatc.....,.t

I hav.. k.,.,u„ tlu. i.t.r.i.s uh,.,, f.lt 1,v r.-.tu... .h.^ml,,..! as ,

tu.......,-. a.,.1 a .list..„.l,.,| un-ur .... tl... h-ft si,|,. as a., ii.tus.us-

cptioii which could Ix- easily felt.

•-' tl... case „f n.aiTicI ^vuunn a va«i,.al .■xa,„inati..i, is
iilx) Usually m.licatcd.

Tl..n. ar.. c.rtuin var -ti.s ,>f acut.. ..hstr.i.ti..,, whi.h
.f.pur,. spccahucnfi..... h. ausc„f th.-ir ..x..,.pti..„al .■l,aract..rs
<..• special tr..at.u,.nt n..,ui.-..<l. Th.'s,. are simple strictures •
various jin.wths .,f the how..), .,r aHectiuy .t s,.c,.n,iarilv • uall-
st...,es . ,„ter..al h..n.ia ; au.l. in tl... lar^,- iufstiiie, v.;ivulus

M...ple stn.lure is n..t a veiy e„...n..Mi .ause ..f acute ..hstruc-
ti"... an.l .s usually tl... r.sult ..f injury Iron, jjut having he,,.
"'I>P«--I 11. a l.m.ial sac, sloughing „f tl... ,,art ..r th,. wh..le ,.t
a.. ...tussus,.,.pt.„n. .uln.rcul<.us or .lyscnteric ulciati..., (n.,t
typl.....i). a f laumatie parfial ruptun- ..f the intestine. „r it n.av
t.)ll.)\v an acut.. iipp(.n(licitis.

The e.,nKenital t,.r.n is not o,.ly rare, hut aln...st invarial.jv
tatul. the UK.- ..t tl... infant ren'l,.rin^r attempts U, reli,.ve th'e
stricture al.n..st Impdess. In a.l.iiti.m th.. presence .,f ohstruc-
tion cann..t be promptly (liagnose.l in tl... maj..rity

In the aoquire.1 f.,rm the meth.nl of treatment' will ,|epen<l
<..! the stage of the obstruction. Should the stricture be 'i
iiarr.,w one it may be p..ssil,le to .lo an .nteropjastv when the
operatiOJi i« undertakeii early, but inter nothing wiJi'be possible

I

Wa'/gSHtM^?

INTKMI.WL OHSTIUCrFoN

.'.Vt

••.Xfi'plihi.' (I I .1,1. r..Mna«tn,M..M> ; uM cx-iM.-ii ..i , -iiUJ. im!
Iftiuth ..» int., tin.- atul III, ,ii.|.tn-.„,|. , M |.fn..i,|,. ,,r lalrr,.!
aiiii»tnin<»i> ; (.'{) niti-ru-iuiiiv.

Till- lii>f.ir> ill iic.|tiir(i| >im),|,. >iricHiiv^ is v.ry ihik I, fh,
of a (.'inuil, iiiva.linu <-r cniiiiiiciicin;; in il,,- >„, ,i| Imiv.I. Im.
has a |„„-(r .•.iiirsr t,, l..i- i|,<. ,,n>,.t of r,,,,,!,!,.!.' ..I.«ti,i,ii m.
Thrn- is a ('•.niplaiiit .,f all.H k« ..I .Mlicky |Mii, in th.^ al..lo,M.i,.
..Ii,.,, accnipaiiinl l,y sjckn.:^ ah i a •• ri>iii;i in »!,.■ ^t..,„a,l,."
Visil)!.- iicriHtalsis ,s t<Mii„| if thr al* luin.'n js .■x.iiiiim.mI .luring
one of llirsc attacks. Tl,,. i.fta.ks I,, ; |,,r a vaiiahir time,
hilt n<:iir ami incrcaM- in Mvciity. l-i ||„- (mm- of v'nnvflis'
loiiimciH-infi in the \*,ill of tl„. small iiit.slini- the .ris,as<- is
UMially far advanced wl,<ii found ixcarM- tlic cont.nfs of tlm
^»lllall iiifestiiK^ hciii;. fluid aiv i.|, lo pa^s tliroiiifli a small
opi'niiii.', and it is a loii^' liim- l.ilm. ih,. .jrouth fori'rict>
suflicicntly to produce syinpfoin .

">' Sun.lav. l»..r,.,ulM.,- 14. l!li:i. f. K , ,„..■ l- I... uanl „. wl„,h .1...

Iiiul |>n-v,(nisly Ix'ci, a patinil i,. ,,.i|i,,-.i | . i.„,--i,.i, i, ,•,.• I,,,- di..

wiinl IVslivili.-s on (•li,lslnias Da.v. \Vllil^( ..i , ,,.. I,., |.,i ,| ,1,.. 1, „l an
iittiu'kolal.iloiiiiiial pail, aii.lv,.,,,, Ill,;;, Tl,.' r..i.l.',i M,>i>ta,.l mi, t.'.„ii
.•xamin.'.l I,..,- an.l lo„„il so,,,.. .Ijsi.i,,,,,), „| , i„. mIi.1..ii,.ii « ii ii pcii>ials,,
A l,isl..i.v ..t MHiilar alla.ks lo,' a p.tuhI „I ili,.... w.ks «as ..l.tam.Ml'
She was a<tiii,ll<Ml ami opciali..,, p., I..,„,.'.l tii.' saiiif alt.Tii.M.i, as ,t was

*'^''''''" '*'" 'I'^' ' i"-l '"" " a> pi.MMil . 'ill.. Ii„e ..t til., pivvioiis ii„.i,„„is

(•^.'<" !>. 2«7) was si.|.'cl...l as t|„. miis.lr lil.ics l,a.l ,i.ii i,ii,iril \mII

an.l th.'iv was a w.^ak wall Ih.^i... \\v r.iul.l also lr,i a ll,i.-k.ri„i- a t

the size of a <1,.m-,.v aiiit.-r ||„. iipp, r .■\(,f„Mly of ilic scar. iliis was
a.lli.Mvrit anil pla<'..l al tlir aiii;!.' ol lli.^ loop wlii.l, ha.l !..•.■„ >lioii-
ciriutc.l Lffoiv. 'I'lici.' wcif<„„. oi Uvoa.ll,f-i(iii- InUVfc, I lir oMK'iitiiii,
an.l ..111.-,- i,a,l.. an.l wli,„ llir p,.U is was .•xploi.a a ninioii, , ,,i,|,| l...
l.'ll wlii.'li was a. II, .■lent l.i ll,.. siuninil ot ij„. l.la.l.l.r. It wa> M.tnc
.lislan.-.' I,.>i,i 1 !„■ ]>oi,it of latcial ana>l..i„o>is. .'n.-iirl.'.! I hi' >iiiall 1...W.-I.

but (li.l not .|nit •.■linl.' its Ininm. Tl,.- wail of ll,.' l.ow.'l al.ov.' an.l

below .•i.nld be pivsM'.l into it. Hs >l,ap.-. iiit«'i,iall.v, i.>.i,ibhn- a .lie-
box. 'rhci-.' was a taj; ..f ..inmliin, a.lbc.'i.t to it. I be iiii'>cni,rir
K'tands wciv (■,,la,i;.Ml ..vci' a la,ir<' a,.'a. Aft.',- .■vt.iiMoi, of ih,. ;,b-
.loininal ii'ci>i..i, it was pos>il.!.- 1.. .-nt awa.v tli.- •.',.. w I li f,oi,, tl,.- >i,„i„i,i
of 111.' blad.l.i. tl,.' wallof wbi.l, wa- siitnicd. The p.iii io„ of >n.all «i,l
attVci.'.l by th.' .ri-owtl, was .'x.iMd (>il iial.'.l about :i f.-.'t fi'..ni Ihe valv.')
with af»'WKlaiidsaiidan('i,.lto-.'n.laiiast.,nii)sis canicl out. The j:laii.ls

were much too ninnei-..tis joi a ,,p!ele opeial i.tn. The small int'.'stine

ab.ive the jjiowth was dilat.'.l an.l .■onu.'sted, that below soniewliat

' All interesting papci- by Dr. Spcesc on -arocnia of -mall intL'siue, will W- f..uii.l
in the " Annnls of Siiigery, " 1!»14, (.. 727.

254

THK ACITK ABDOMKX

\ii'

J

r ^..•

I'l:

*•',•

smalNT than nnnnal, hull lM.rniaa,.vidw.MylMMMM,o,.om,,lHrol,str^^^^
<•«••'. Into wa. a jroo.l .Lal ..I sl.ork all,.,- tl... .,,M..aiio„ an.l tl>,. ,,„|s..

s;.;:^,^:;'''^' ='■'*■ •'••—'■'■•"■'■':••■.- ..,...;„.,..

Mr. Shall.M-k r..,,orl..<l d.al Ih,. .nnvlh wa. a roun.l-...l!,..l sairo,,,-,
At ,„u. ,,..,l.t thr j:n,wth ha.l Imto,,,,. n...-,OM..l an.l l,..,v 1 1„- .„„,.,.tu,u
was adhnent ..Mrnially so pirv.-nl in^ |«-iloiali..,.. Thriv ha.l Imm-u no
l)la(lilfr syniiitoius.

<»■' .lannaiy i>(i. K.U. rxplorai ion was a.uain p... lonn...l ,o s,..- it ih.-

;.'hiii(ls would iXMinil of icnioval

now tlial tin- patient was in

I'i'llcr licallh. l)Ut. althou;;li sonic

"I 'licni were sinall.r. they wcic

Vfiy<-\l|.iisivfly attcctcil aiiil one

(11- two iiodii'fs ol jirowlh coiiM

hf fell. 'I'ru days later the use

<il t'oleys lluid ill iiieieasjiij;

^-2 doses was eoiniiieneed. She iefl

nil I'el.iiiaiy 12. I'.lU. lor a eon-

valeseeiil home, fioni whieli |»i.

.1. <;. Diincanson iciKnIed a irain

of weijiht of ahoiil ,' |1>. a wee!,

I" ilie l.eirinniiij.'ot .\piil. witlioiii

any si;;iis of ahdoniiiial disease,

iUid she (onf iiiuod well when seen

in Aufriist.

\VI)':i :i siuvdiiiiitoiis i.'!-{)u t h

Fl(.. .M.-Sarinina of Small Intestine <lcvi ,.- ilH llf llU'S«'iitcrv ol

l>rodiieiii- ohstiiiction in a child. f|„, ,,„,., n ;„, ,,(:. •. "

I. Kaised edj;e of ;;,vwth, n,>t hard .^'" ' '"' " "1«*'^«"'«' It may

or everted. 1'. I!ase -,,inur thn.li;.-li I'lVil'U till' lllf Cstillill Willi and

lnd'"4^n""w"v- -V^?;" "^''■'' ^•"'-'^<'" '"t" "^ I'""*'"- -
II. Ki 1,'ivoii way. I, niiicntum . . ,

attached and ]iivventiii- jjcneral Prodllc'.liy oiistrili'tlon.

])Prit<initis. .',. Situation 'I)f attach-

iiieiit to l.iaddcr. Mr I'., ayed .".o. was seen in

einisiiltalion with l>i. \ I"
•■nd.trey on May |-'. l-lll. lor a swellni- in the lower al.don.eii ' T, "
ye s l„.|ore he had had a swelling in the uj.per alMh.inen whirl, d
■ared. I here had l.eeii eomplaiiu of iii,lij.esl ion. I.ul no vonulm.'

ill.' swellins; of whieh he now eomplaiiu'd was nolieedal thrisi,„,T
P.Mii. and had mereased slowly without pain. The .eii-n,! appearaii e
"I the patient was that of aheallhy man. In the lowr al>do„ien was ■,

tiunoiir the size and sha f a .•...•oa-iiiil : it oeeiipied ih.. mid line and

eaine lorward al.ove the piil.es like an enlaij;ed l.lad.hM' It wis 0,1,,.
linn, teelinj: like a lil.roid -rowlli. and was lix,.,l posteriorly lo the
ti.ssiies at the l.aek ol the ah.lomeii. hiil eoiild l„. moved to some exleiil

lie eompUined „l some loss of ai.iH'tile, althoii>;l, this was nev,.i ,d

and he had to take medi<'ine to ensure an aeli..ii of the hovels

wo

i^-

i:::\fi^m^mum:jR3!s^i^^B£ismB£SiiiyjS^'t-:mi^^mK^j^ji

INTESTINAL OBSTRUCTION 2.-,o

Tliis tiimimr wiw rcinovt'd <>f Hay Is with tlic li.I|i ol I>r. A. K.
(HMlfivy, tiK' itiiU'^llictic l)|.inj; M;iv,.,i l>y Dr. 1'. (...illny. Incision was
made to flio iij;lit of thu uiiilillc line .mil \hr vi-r\n> (li,|.hiic(l
outwiiids. Tilt' tiiinour was gn.wiiig iii ilic m.'sciii.Tv oi i lie ilfiim.

- H y-

T, J. >.

and was dilliciilt to lift out tiiitil an adliosioii to the |)critoiiciiiii on the
liiilit side of the pelvis Iiad been divided. It was crossed by a loot) of
small intestine (ileum), wliicli was closely adlieient.

'I'lio •iidwlli was very Iiaid. t'l.iini)s weie ajiplied to tlie small
iiitestiue involved and IS U\ 20 inches of it were removed with the

i

256

THE ACL'TE ABDOMEN

li

r

I

H

tumour ami a iaiiic Vsliajii'tl poriioii of tlio ini'sciilt'iy, rlio vessels beiuff
serured as they presented themselves. Kiid-to-eiid aiuf.stoiuosis with a
double row of eoiiliiiuoiis sutures was peiforined and Ihe niesenleiy
sutureil above and undernealh, no raw surfa<'e l)eiuj,' left. No glandular
enlargement eouid be found. The wouiid was Closed in layers.
The reeovery from tiiis operation was uneventful. Mi'. Shattork
reported the nature of the jrrowlh as spindle-eelled saironia. and the,
sperimeu has been added to the eolleelion of tiie Royal ('oliege of
Surjieous.

The si)e<'imen shows funjjation of j;ro\ytli into the lumen of the
intestine, not completely l>loekiiiK the canal. Some peritoneum has
been removed to show the rough section of the main growth.

This patient was seen again on .March 4, 1!)12. During .lanuar.y and
February he had two illnesses with night sweats, with some fever
(102' — It*.'!') lasting a week (ui each occasion. There had been no ])ain
or bladder trouble, btit he had constipation, and for ten to fourteen ilays
liad noticed renewed swelling in the lower alfdomen. 'i'his was rounded
in outline, tympanitic on percussion, and appearc(l liuctualing.

r.xi)loration on the !>th showed an extensive growth with a broad
base and inliltralion of the mesentery. The peritoneum was very
vascular with a <|uantit,v of large veins. The lluctuation was d>ie to
liirmorrhage into the growth: It was not considered operable and the
incision was closed. The patient died in the following .Inly. ('o!ey>
fluid produced no effect.

A hytlatid cyst may pros.s upoii tlic iiitestiuc wlion it grows
within the mesentery, or compress tlie large bowel when it
develops withiii the pelvis. Utenne fil>roi(ls are very unlikely
to cause acute obstruction, but it may ari.se as a secondary
consequence owing to the format iiii of bands or adhesions
when there lias been iiiHanmiation of a fibroid [lossibly due to
a twist.

Obstruction' of Small Intestine, duk to Adhesions .seconuaky
TO A Pedunculated Fibkuid which jiad undkkgone Kotatimn'.
— .\. M., a married woman, aged 48. was sent to me by l>r. Sonlhey. of
Colnbrook. on .May 24 and left .Itme lo, l!tl2. The calaineiiia had been
more freciuent an<i irregular for twelve nionlhs, and she hail noticed
increiising stoutness for six months, during which time she had suffered
from occasional pam in the abdomen ainl bai'ka<'he. On .Ma.v 12 she
hail been taken with vi'i.v severe pain in tin' al)domen, which had
continued since, with constipation <>n the 22nd she had vomited, and
this had occurred often since. She was ,i thin, wrinkled woman looking
quite old, rather restless, and coni)ilaining of attacks of abdominal pain
of varying severity. On examination of the abdomen, there was a
hard centrall.v-jdaced tumour the size of a cocoa-nut, reaching above
the umbilicus and going down into the pelvis, whi<'h it tilled. It was
slightly movable. (.)n opening the abdomen we found th(> omentum

INTKSTIXAJ. OBSTIIICTION 2.-,:

iMlliorcnt to a ;;iv.visli.l.i„\vii mass, and Ih,. traiisvri,,. .ol,,!. ami -.inaM
«iit wciv also adh.-icut rouii.l Jl. 1( wa. a iMMluuculalnl (il.n.id wlji.h
had uiidef;;oiic .iiic .•(.niplrtc r.Hali.iii mi ils |.fdi.-|... wlii.ii ua> aila.'li.d
to til., fundus utcii. S,.vfial l.aiids w.-iv divided and a multilorular
cyst of tlic rijjlit ovary rt'iiiovcd. A irioovr was found in Mir wall of
the ileum mil te hy one of the lai)ier l.amls. Al.ove llij. 1 1„. ii,i,.>ii,„.
was distended, helow eoutraeted. 'i'liis ;:i<),.ve was invaj;i;ia!ed niiii a
eoiitinuous Leiiibeit suture.

Carcinoma is very ran- as a priiiiaiy growth in (Ik- small
intostino.

1 have only been ealled upon to o|terale for ii once; it was in
the jejunum hij;h up. There was mueh glandular enlaiv'emeni . and
some seeonilary deposits in the pe-iloiieum. A lateral anastomosis
j{ave relief.

In obstrnetion from gall-stones tlicrc is a ditfcicnt cliiiical
picturi'. A suddni attai-k ot jiain in the upper alxiomcn,
with vomiting and shook, in a woman of alvancing years.
The v(miiting is troubk'somc, and with the pnin. which is
paroxysmal, varies much according to the progress or arrest
of the istonc. The majority of stones are arrested in the
ileum, because this part of the intestine is the narrowest,
especially near the ileo-ca'cal valve. Init arrest is common in
other parts as a result of muscular sjiasm. Absolute obstruction
is temporary high up. J)uring this time there is no action of
the bowels. The pain moves to the ni'ighboiirhood uC the
umbilicus, and if the woman is thin the stone may be felt
until a spasm of the bowels occurs, when j)erir.;alsis will be
seen and tenderness compl,>'ni'd of.

The stone which is shown in the illiis! lat ion (Fij;. ;i(i) was removed
at operation from a stout elderly woman, and before oiMiaiion eoiild be
felt y)fr icition as a hard, very under lump in Doiiulass pouch. Tin-
mucou.s memlnane was ulcerated over it and oi a dark colour, maldni;
it probable that the stoi;e had lod^'ed there lor some t inie It could not;
be moved iu either direction. The patient, who was very ill. did uot
recover.

These cases may go on for a long period if no operation is
done.

I once saw a \ nficd lady in consultation who had had symptoms for
eighteen days, : nd a.s she was in bad health and unlikely to survive any
operation the effect of local application of ^'lyc(>riiie and belladonna was
tried. On the tweuiieth .l.^y die passed a blip- mm facetted stone.

A. A. S

m

THE .\( ITK ABDOMKN

l^-

111 anotlicf case the laily liail been MilTcrinj; willi varviiifi
symptoms of (ilistnu'tioii. ami was fxtrcmcly ill. Her state
was thought to he due to a gall-stoni'.

<hi Miiifh 2ti. I!tl;i, ji liul.v of (!."> was seen with lir. S|i;iiill in coii^nlla-

liiia Iki iiitcstiiiiil olislnicl ion. 'I'licif w;is a liistdiv of nil iiti;(<k d

jrull-sloiio live ycMi's Ix'toif, aii<l the |iicsciil illness l)ci;an with ratlifr

scvfic (•|)if;i(>trii' pain on Maicli l.'t. She lia<l vomit ini; anil was vitv

ill for a tlav or twn ; iniinovcnicnl cusufd. Init she kc|il her linl anil Ini

I'onilition variril fioni ila.v Id ilav. 'I'lir pain It'll I lie cpinast lic ir^iion

ami lias vaiii'il in position sincf, lii'in<: niostlv in llie iiniliilical r('<.'ioii.

< III t III' 24i li sill' liail a scvi'ir at t ai'k of pain w it li vomit inj; ami was vcrv

ill. with a lapiil pulse. Wlicii seen on llie 2filli she was feelinj,' niiieli

lielter, liavini; (lasseil wiiiii. ami at no time

•Iniinj; the illness hail she failed to have an

aetion of the Imwels, aftei elieiiiala. fof mine

than a ilay or two, exeeptinj; iliiiinn t he

ailaeks of jiieater jiaiii. The patient was

rat her stout, feelint; ill. ami not aide to talk

elearly aliotil her eomlition. 'The alMloinin

Wits .soinewliat ilistcmleil, without riuiility or

l)ariieiilar lenih'iiicss any where, ami without

tunionr. The lonuiU' was fiiiied and the

liowels had aeted after an enema. I'lilse. !h( ;

leinperaltire. '.til . ."^ulTers from iiii'inorrhoids.

She had an ainle olist riiil ion on the JSth

anil2<.lth and almost died, but llii-was relieved

l"l(i. .)(). (iiiU Stcine, lowaids the eveninj,' of the l".Mli. i in .\piil I

natural size, removed s]^^. prolialilv passed the stone ihrou^tli the ileo-

from the Miiall lutes- ,,.,.,..,, ^,.,|^,,;_ .^^ i„,,,roveiiient l.ejiaii. and the

tine duiinLT lale. It , 1.1,1 1 . , 1 1

eansed .Vente . il,-tr.u - ■-'""«■ "as Jiassed towards t he end ol the week,

tiiiii' St Thnnia-'s al'ont twentythree days lioin the eommeme-

llosiiital Musenin. meiit of symptoms: for a time il was li\eil at

the anal oiiliee, She lefiaiiied her iisiial health.

'I'lie stone was not eoiii)i!etely eyliiidrieal, heini; i-oin)iri'ssed laterally,

measiiiiiii; alioiil H iiuhes l>y l| inches: one end was facetted, the other

yininded.

In s|)it(' of Muh cases, early opei'titioii gives the best ehaiue
of sueeess.

If you iiiul a patient wlio is too ill, or who refuses (.)i(ratii)n.
in whom you diagnose gall-stone obstruetion, you are not
justified in withholding all lioj)e of recovery. You cannot
estiiuiite the exact si/e of the stone, and there is always a
ch.mei' that it may be forced into the large gut at any moment
should rela.xation of local muscular spasm take place,

^Vhen \ou find a i;all-stone in a coil of small intestine the

■f

TXTKSTIXAT. ( )l5STI{r(TI()N

2.V.t

i»i'>t trvadiiciit is ti) <lrau (he liiii|> niit-nlr. p i>li the nI.-mi'

llij^llfl- ll|l llic llDUrl (tnr Vdtl cailllul ( .-.IlllKllr llic aillnlllll of

iiinil>iil cliaimc ill llic ciicircliiiu imiic.iii> mcii.liiaiu). an 1 cut
'Inuii iipiiii it inmi the antr-iiii>cmciic Ixuvlcr. -iiliiriiiL; the
iiicisio-, throiiirli wliich it lia> hrcii .■\tiac1:'.l -.vith ;, ,|,,iil)lc
niwof (•(mtiiuiniisviitiins. thciiiiicr liciiiii pa-scil tlinxi^di all the
coats, the outer throiiirli |)iritoiicum and nuiscular lavci- only.

Acute obstruction the result of pas>, yc ,,\ the small intestine
throujrh an aperture is not often seen. althuuj.'h several eases
are on reeonl. There i> a specinicn in the St. Thonias's
Hospital .Museum (KIl'. n). which shows aii aperture of the
hind, likely to snare intistine. in the mesentery. Apertures
may he conjicnital or the result of injury to the ah lomcn. TJie
sym|)toms arc those pio luce;! i»y „ hiuil in a similar [losition.
These ol)structioiis are iruliideil under ,'ie Ilea lintr Internal
Hernia, which also comprises the eases where intotiiie hecomes
entangled in a rctro-perkt.inca! poiuli. the foramen of Wiiislow.
or in an openiiiL' in the diaphraLMii. I'ouciics which have been
tound to ensnare intestine are found in both the upper ami
lower abdomen : of the former there arc the duodenal (ri<;lit
anil left); of the latter, the inlersiiiinoid. the retroca'ca!
and the poucii of J)ou<:las. As these pouches can mo.stly be
demonstrated in the anatomical department ami they rarciv
cause obstruction, it is luobMble that some abiiormalit v e.\i>ts
when the intestine ucts ensnared. As a rule the .ipcrture can
be dilated ; if iiici>ioii is reiniircd. the possibility of the presence
of ves^els in the constricting fold must be rciiiciiilicrcd. After
the intestine has been reduce 1. the openinu of the pouch should
be closed with a stitch. This statement docs not appiv to the
foramen of Winslow. where the ,-ur<£con should not attempt to
(dose the opening,' because of the very important vesx Is which
surround it. in hernia into the lesser sac. in addition to acute
syiii|>;oms there is a dctinite swellini,' in the epijiastric rei.'ioii,
with po»il)ly retraction of the lower abdomen, it is possible
that if the distended intestine which oc(aipie> the lc»er sac
ami forms tiie tumour can be emjitied. traction from outside
the foramen w il! reduce it.

in duodenal licrnia' it i- possible to tind a swelliim in 'lit'
rcajou of tile umbilicus. Init in thi' serie:, met with in the lower
abdomen tiiere is no special guide.

Ill

:'!

!ir ;

ItiO

THH .\( ITE ABDO.MKN

I)iii|»hia<imati<' hciiiiii i-* well illustrated by the (Iriuniitic <a>*e
'vhicli has hccii ivlatcd (p. 2:W).

The ahdomiiiiil ((mtcnts may pass into the chest and heconio
sttaii<iulated thmufzh one of the natural openin<is of the dia-
lihrajiMi throu^jli a eonjicnital (h-iicieney in it. tluouuli a wound,
or tln-ou<ili the scar wliich follows a wound. This hernia is
rarely rccojjniscd (rurinii life, hut a consideration of the history
with' an examination of the chest may assist tlu- surjreon in
arrivinii at a correct solution of the case. The sij^ns in the
chest are ofti'U similar to those produced l)y a pneumo-thorax,
with (iNspiKCM ami i)alpitations. Before strangulation of the
l>rotrusion has taken i)lace it may assist diagnosis if the i)atient
is examined witli the X-rays, but as the stomach is often
implicateci and vomiting fri'tiu(>nt, when severe symptoms are
.leveloping. it is often too late (see '• Strangulation of Stomach,"'
p. 2:J<1 . ■■ Kupt>ire of the Diaphragm." p. 15).

IXTlSSrst KITIOX OR IXVACIXATIOX OF THE

iiOWKL.

Under this heading is comprised a large group of the obstruc-
tion- met with in })ractice : in fact, it is so large and important
that it re((uires a section to itself. There is hardly a week
pas>es in which tin-re is not some case admitted to the ho.spital,
and .»s a r\de they are ))rought at a comparatively early stage
of the oi)r-lru(tioi\. because of the passage of blood from the
bowel. This >ymi)ton\ is one which ])rofoundly impresses the
moflier of the child, and she caimot pass it over, as it occurs in
;( I iilicn to pain of which the child gives evidence. She knows
l\, <■;•'■ is sometiiing wrong inside.

In this form of obstruction as met with in the living subji'ct
a varying amount of the bowel lu'comes invaginated into a
section below. Thus a tumour of varying .size is produced
which con>ists of three layers— the entering, the returning, and
tiie ensheatliing. Thesi' layers, with possibly some omentum,
form what is usually called the •"sausage-shaped"' tumour,
wliich is so ciiaracteristic of the disease when it can ))e felt.

It is ,-ometimes, especially in the chronic form, met with in
adults, but is by far most commonly seen in children (male
chiklren) unilcr one year old, A remarkable fact, which has

^:fc^^cj&

TXTISSUSCKPTIOX OF TIIK V.OWKL

Kil

hrcn inciitidiicd hy many writiTs. i> that I lie patiriit at llir
tiiiw ot onsci nf till' illiu'>-i i> ot'ti II a \(iy In althy and well-
iioiirislicd child.

If is i.'(n(Tidly jickiiowlcdiit'd thai the cauM' mI iiiiii'-ii.-ir|i-
linn is an irr<'unla.i' peristalsis ot the howcl. |in^-diiy dnc to
intestinal irritation troni within. 'I'hc aetnal iaii~c ol ihi- i>,
however, dithenlt to trace. There Mia\ lie som.' -uillin. ot a
I'ever's ])iiteh, a Ineniorrliaue into the nuicous nieinhram or a
polypus to start it . There is no eliiiierd ad\ anta.'e to he (|eri\ ed
iroin a iniiuite division ot tiie varieties of intn-.Mix-eption. and
students only become confused if ti rms aic inidti|)lied. 'l"he
di\isions into enteric, colic, and entero-eolie. a-- >n'_"_'e^ter| liy
Mr. ('. S. Wallace, are (pnte satisfactory : more are ^.iipeillnoM-;.
I'ractieaily. reiUicihIe and irrediicil)!e are iccoL:ni->id.

The svinptoms are those of • ])eritoni^m." >udden ahdominal
])ain. vomitinji;. and shock, followed liy the pa-saire <if Mood
from the rectum and the formation of a tumour in the ahdomen
which can he felt.

There is a history jziven of a sudden sereamiiiL' <iii the part
of the child, which looks friiilileiied. and lieconie^ u liite-faeed
evidentiv fron\ shock. X'lunitinji soon appears and tiie child
rallies from the shock, hut the attacks of pain and screamih'/
contiinie at intervals, 'I'here is an action of the howeU. which
contains little if any faecal matter, hut con>ist> mo-tiy of
mucus and hlood.

If the ahdomen is examined hetween the attaek> of |)ain it
will he founil llaccid and without di-teii-ion. S<mielime-- the
child is found kneeliim in i)ed with his head hinied in the
))il!ow. Kxainination is n<it resisted as a rule initil the -williuL'
caused hy the intu-sn.-ception is tiaiched. when there is a
complaint of ])ain. the lump iiardens. and the mii-ck- over it
liecome rijzid. Sometimes rigidity is presetit when the child i-
cNamined and the tumour cannot he felt. e.Namination I.eiii-r
resisted hv the friiihtened child, who instinctively harden-- the
ahdominal wall until an aniesthetic has heeii Ln\<ii to relax t he
muscles; hut this iuiic-thctic should only he ^i\eii when
arraniicments to operate have already been completed. The
tumour varies in .-i/.e and jiosition. and i> like a larue sausage ;
in the earl\ stages it will lie most fre(|Uently found on the ri<:ht
bide below" tlie liver. .\ rectal exaniiuatiun will often prevent

2<J2

THK ACITK ARDOMKX

I

! ■

the useless administ rut ion of an aniesf hef ie. for in eases w lien-
no Itlood lias been passed some may he tound on the lin<;ei'
when it is withdrawn after this j'xaniinalion. In addition, the
apex of the iiitussuseepl ion may l)e felt as a riny of mucous
mrmhrane within the rectum, into which the linger can he
passed. The tumour may also he felt him.nmally. hut not as
a hard tumour, in the pcKis outside the howcl wall. In eases
w here there is prolapsi- of the intussusecpted jiait this has heen
mistaken for a prolapse of the rectum, hut examination shows
in the latter that it is not possible to pas.- the lin;ier uj) the
bowel by the side of the |)r<)tnisioii owint,' to the attachment of
the skin.

'i'here may he no action of the bowels, hut complete obstruc-
tion is very i.ue : usually the intussusception permits the
passai^e of intestinal contents throusjth it. therefore distension
may be reji.irdi-il as a had si^n. When it i ^ present the case is
a late one. and there is j)critonitis as a. complication.

One of the sijjns of intussusception which is not of ijreat
value is that known as the Siu'iie de Dance. It was lirst
described by M. Dance. "' .Medicin ile I'Hopital Cochin." Paris,
in 1S24.' It is a|)plied to ihe condition of the ri;;ht iliac fossa
when the ca'cum has heen drawn away in an intussusception.
This withdrawal of the u^ual contents is supposed to leave a
comparative hollowness of the fossa when compared with the
other side.

.\dauis and ( 'a.ssidy (p. ISi') say that they have known
■■ abdominal .section performed when the tmnonrs were respec-
tively the lower edge of the liver. Keidels tongue-shaped
projection from the right lobe of the liver, and the right
kiilney."

It is. however, obvious that a child with the |)assaiie i.t
mucus and blood from the bowel anil a tumour in the abdomei:
should he thoroughly i-xamined. but the history given in these
cases should |)revent tnmeeessary opening of the abdomen.
Henochs pui'pura is sometimes associate, 1 with an intus-
susception and may rccpiiri' mechanical assistance to reduce
the bowel to a condition more nearly approachini' the
normal.

Tuberculous affections of tln' g'ands. (iMicntum. and peri-

I l!r|icil. .I'Aiiatuiiiio. i-ic. isjl.

i\rrssrsr'Ki»TH)N <>k rm-: n<»\vKi, •2^\:i

loiu'imi arc iiiinh iiiun lik<'l\ tn ciiu-i' diMiciilty in iliav'iin«i->
in clu'onic ratlicr than in a( iilr intu>>n«i'<'|)ti(iii. Tin |iii>iti>>n
of tlic^r If^ions. flu'ii' >lia|>i' anil nnnilxr. >*ill liil|i in lln-
(lia>inii>is.

W'lirn llic inln»u>c(](linn li,i^ oiuc cipnuncnccl. tlir .i|>i-\ nt
tlic cntt'rinji pai'l remain^ cnn-tant and inc Iim-c^ in -i/.i' a- a
ri'snil of cdiiiif^-lion liuni intcrtVicncr uilli llic \' mai-. i' tnrn.
By peristaltic acliun nf the >lieatli it i- Inircl tnrllirr ilunsi
luitil it may prolrmlc inmi the anu>. Meanwhile the ennije-.-
tion nf the enterinji lavvfs has extende i in ainmint and t he
ditliculty in rediietiim increased. 'I'lie Mie-cnlei\ ciiti i-- with
its seetiiui of howci. and l>y its pull on the eloimaled swelling
causes it to assume a eui've «itli it-- convexity I'.ow nw ards.
The compression of the mcscntiiy incrca-e^ the m uou- return is
more imjM'ded. the howcl forminu' the intu--sn-ceptiim hecomes
more enuorjied. There is an increased t!o\s ot mucu> tinm the
surface, the ? rr; illcr veins \ ield to pressure, and a~ time pa--e>
thei'e is an escape of hlood-staini'i nnicus fiinu the ann--. and
ha'Uiorrhaiie into the tissues from which it is cscupiic.f. Adhe-
sions Itelwccn the opposed |iei'itoncal »urfacc'~ form earlv. and
if I'elief is not atfonlcd within a few lioni- Lianj^rt ne of I lie
intussusceptuui I usucs from com|>lete ^topjiaic ot circulation,
aided l>y bacterial invasion of the dama^'cd ti--ue-. I'eritonitis
isafrcipient cause of a fatal endin;_', hut the jiaticnt rarely die>
from com|iletc olistruction. If. however, the stran'^uialion of
inva<;inated howtl is complete from the first. Iiloo:! and mmicih
will not he passeil.

If no attempt is made to relieve the ohstruction, deatli
Usually occurs hefore many days have passed, and aithoU'.di
spontaneous reduction is >pol<en of. it i- one of iIiom' riire
occurrences \vhi(di caimot he seriously considered. Some r -.Ms
a>;() IJrintoM made a collection of "»<"► fatal case> of oh>truciion
and of these iM.! were inlussusce|)tions. .\iiothci' wa\ in winch
a |)aticnt may recove • is }»y sl()u<^hinij: of the intii^-u-cciitnm :
of this there are many Uiiown instances.

.\ cliild uikIit my >ai<' .n liic iioyal I'icc i|(iv|.i!,il \va> -mITitiii;; tioiii
iiilussuscciilioii Willi iiicil:iii~i- tdi wliicli I lie pairiit-i irtiiMil iiji. ral iiiii.
'I'lic I'liilil was lakcii liiHiic lo ili>', ami wa- iiiclir.l vny ill. Mkhii a
fiivliiivlil atlcrwaiils ilic iliox-r dl 1 lir ca.-r wa-^ walkiii;; llinm^li l lie
.-tivfl when- the taiiiily roiilcil ami t.> li.-r suiprisr >a\\ iln' tniiuci

9PP

2«l

THK AcrrK AllDn.MKX

H

■ I

|)aliiMi |>hiyiiu wi li «>;li<i rliililii'ii ami •-ui'kiim ,111 i.iiifiiic Sh,. rii.i.)''
iiH|iiiii.-.. anil Mil- i.il.l ili,il a Irw ilav- allti Iim\ iiik tlir li<>.|iiial t lie
|mitiiiii i>l Idiwcl whicli wa-. |il<)la|>-i)'ii when lie wriil Imiiim' ii ii| riiini'
a\\.i> ami I lir rliiM ia|Mill\ rrcdvci.ii iMaitli It i« not |mi--iI)|.' In -ay

it -ll ill (llf l|tvilc>|ii(l lair? .

It i> iiitnivtiiijr ),, ^,.,. i|„. viiriiMi- m(lliiMl> of tri;i!m<iil
wliicli liiiAi- l>(( M tiinl ill the |iiis|, many tniiiiilcil (ni a complctr
failure In imdciNtaiiil the |i,i(linl(ij.'y u| tlii- discjisr. Kattyc
statiN that caM-. havr liccii ciirril hy tlic |»a>>ap' of linimic-
ii|) till- rcctniii.' Mayiiicii. <it Arvnil.- ii>ril a inixtiin' «tt
No. ."» -.jiut ami iilivc oil. 7 o/.. of (In foriiitT to J o/. of the
latter, ami (|ii(itei| tuelve ea-is of -iipposed e,\aili|iles ot the
(liseax- thus treated.- lie has not found many imitators.
'raliafeiTo relates the ease of a prisoner who was eiired li\ the
Use of elfei\e.-ein;r powders in the rectum, hut died of |,arotid
huhosonie weeks later; his uaoler acted as medical ailviscr. Iced
injections have also hceii tried. The melhoil of inllation vvliieh
was in voyiiesonie t w en ty years auo «as introduced livd .rliain'
in iN.'iS. This when comliiiicd with external inaiiipiilalion and

the use (ll chloiiilorm in cliildrei t iiifrcipiciit ly ^iiccccdi !,

hut was uncertain and not wilhoul risk. Clieadle' wrote of
this method : • The .-ucee>> of inllation in the cure of intus>us-
eeptioii depends laiMrely. no doiilil. upon its early emjiloymcnt.
Ili^'iiiiison's syrinjic proved of most ii-c." FayL'c ' wrote of
the same treatment : " It has now been freiiuently em|iloye(l,
and sometimes with the icsiiil of ciirin<; the disease. ]\lore
often pirhap- its success has heen partial. The tumour has
hecn reduced in size, or it has chaiiiied its position, returning;
towan'- the seat which it had occujiicd at an earlier period '
Hryaiit wrote warnin>.dy : '• Bowels have been ruptured bv 11-
Use." The siilistitiitioii of water prcsxire. by means of a
funnel and tube introduced into the rectum, care bein^r taken
to prevent too much force bciii;.r ein|iloyed. has been similarlv
tried, and with varyiii<: success. The funnel should beelevatcil
about L' feet above the level of the rectum and warm saline
solulion allowed to How (|uictly into tin bowel whilst the child
is under a uciicrd aiiiestlietie. .Manipulation of (he tumour

' !••;::-. , -.Sv-trlll (,f M,,liril|f." Vol. II.. |.. 4 lit.

- /.,/«<■.■/. v.. I. I., IS7II, |,. 7:t7.

(■iiy"- lln>|,itiil l!r|„irt-. \'<.|. III.. ]). :!(.".,
■ /.,n/.;f. v.. I. I.. Is,s8, p. IC'I,

INIl'SSl-scKITlOX (H' TIIK llnWKI. .'.i,-.

throiiuh the alxlitiiiiiiiil wall .liuiihl In- caritiiliy . arn.n >,u ,i«
Hu' ifijfctiini ciitrrs. It i^ a iihIIihiI uliicli I lia\ c iim.I .||,. ,•(•<.>-
fully in thf past : it ha,, lucn .tlta-i lomd iMiaii-c ot it; iin-
<Mitai!i fiTict. yt'l iIhtc may lif imm a-iniis whin it will a|»|iiar
ti. till' alfiii.lant well worth a Dial. '!'.. -n.ic.Ml the cax-
shniild he ,in .ally one. 'I'h.' cuMiliiiiatinn i.f tin- nKtlii. I with
that (it lapaioloniy has hrm toini'l u-rtnl hy ^i.ini'. lint it iv
Iti'ttir in my o|Hiiii,n to tni>t cnliii ly t.. u|ii'nin<: the alulonicn
with mani|inlali<>n ut the intii->ii„(.|,ti,,|| Inci^inn mi tin-

l''ll.. ■'iT. h'llhlctiiin iif lill IlilU — ll-i ••]itliill ]i\ Mulli|nil:itiMll .,,lt-hlr till'

AIhIiiiik'Ii. 1. Iiitii-~u*i i|iifn-*, li:iiis~ii-ci'iitiiia. 'J. TIk' I'liit'imiil
ciivity li;is li- ■■ii ip.ilUuiI '>tl' with ;.mii/i-.

li^ht side over the icctii- luiix'lc. with (i|Hiiin<.' i>i the ^luatli
and dis|ilacci!>cnt ot the nninjnn-il nuiscic dutwards. is the
hist \'i)U will (Hit li:i\c a weak wiiund attriwards. as is oticn
the i-asc it' the fibres of the muscle are separated. The iippir
limit should extend above the umhiiiciis. When tiie peii-
loneiim is openeil. the pi'olap-e of small intestine is pre\(iited
liy a iranze pad or pluu and the |)o-.ition of the tumour delineil.
If tw(i finj^ers ai'c passed to the lowci' end of this and pie-vure
is made o\cr the end of the intu.-suxeptioii. it will ijiiiekly
recede before the picssure until a \ariable amount is left, pci haps
ii linn suusagediUe lump of - inches in length which is mote

•miW'n.

!S

^SfTHEvT^'SnlE^^'ST'l

MICROCOPY RESOIUTION TEST CHART

(ANSI and ISO TEST CHART No. 2)

1.0

1.1

1.25

1^ IH

1^

|50 "^

!=» |12

1^

^Ui,

^ us,

Ills

b

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I.L.I.

||l.8

1.4

1.6

_J ..APPLIED irvHGE Inc

^^ '653 East Mom bfeet

F.S Rocnestc, Ne* fork 1*609 uSA

■JSS (716) 482 - 0300 - Phone

^S (716) 288 - 5989 - fa»

2fl(>

THH ACl'TK ABDOMKX

mi

m

resistant. 'I'liis slumld I)c delivered out (it the wound and
eoni|»lete I'eduetion elVected l)y lirrn hut jzentle pressure. As a
rule some patience is re(iuired to reduce the }(art w hieli has
formed the ape.x of tlie intussusception, and sometimes when
it has heen reduced the operator has a doul)t as to wiiether a
tliickeninif wiiicli is tre(piently felt insi(h' tlie j£Ut is a ^rrou tli or
only conjiested and (edematous mucous mend)rane. It is not
wise to o|>en tlie bowel in order to make certain : growth.s
are very rare in the acute variety and ^ive some distinctive
feature when present. Incision into a l)owel such as this is
inadvisable because the wall is probably softened and contanis
many oriianisms. .Manipulation of the |)arts involved must ])e
gentle but firm, violent or hasty pulling will do harm, and often
cause a splitting of the pt'rit(}neum of the outer layer and
damage which cannot be repaired.

If in spite of careful manipulation the intussusception cannot
be riuluced completely, there are practically two courses open
to the operator in the case of children : —

(1) To perform a lateral anastomosis al)<>\e and below the
irreducible j)art when the bowel is healthy.

(2) To excise the intu.ssusception by the method which goes
in this country under diifirent names: .Maunsell. Jesset, Barker,
etc.

It is especially indicated where the intussuscej)tion is
gangri'nous but the ensheathing layer good. A[)ply a con-
tiniums Lembcrt suture of silk to the bowel at the neck, uniting
the a(lja.cent surfaces in the whole circumferenee. With the
usual precautions against the escape of bowel contents into the
wound, make an incision in the ensheathing layer which shall
fully expose the upper part of the intussuseeptum. An
incision is next made through this close to its upper end. bv
which the anterior two-thirds is divided into the central canal.
Sutures are passed, four in numl)er. through the entire thickness
of this, one in front and one on each side. The fourth is passed
in the following manner so that it may also act as a luemostatic.
The needle is niade to penetrate the two parts of the intussus-
eeptum from within outwards, is passed roinid the vnicut part
of this, which contains the mesentery with its vessels, and back
again into the centre of the bowi'l. 'J'his is now tied, the
complete division of the inner tube.> (and mesentery) completed,

^M.A-

TXTrssrSCKPTfOX of THH BOWFM. 2(17

and Ili<'(.|)cniimiii tlic slicat h doscl willi a (•(.ntiiuinii^ I.ciiilMif
suture, after the part-; liave been cleansed itoide and out with
warm saline.

If for some reason too much damatie has heeii inthclid on
the bowel durin<: the manipulation for reduction to permit ot
its recovery, tlien it must he exciseil : l)ut the |)rouno>;, of this
operation in tin- ease of intussusception is very had. If it has
to he done, the peritoneum nni>t lie packed otT with L'au/.e
moistened with warm <aline and the ojicratinn done swiftlv.

If the jiatient has .stomj the operation well, the wound in" the
.-Uxlominal wall may he sutured a> u>ual : if there is uuich
shock, the lu'st plan is to insert a nundicr of interrupted
sutures of thick salmon jzut. which pass throujxh all the lavers.

It is unnecessary to <;ivc statistics: suffice it to say that
projznosis depends very much on the .d)ility of the surueon to
reduce the intussusception without resection of the inloline :
therefore every etTort short of causinir serious injury to the
bowel unisi 1,,. niade in order to etf'eet that object. Thi. is
niorelikely to be successful if immediate opt^ration is performed.

.V Casi; in wMirii i\n >si scKPidiv i;r.< i itiir.n. I, a i i:i! \i. Wvs,.,.

MOSIS AT .-^K.-.M) OPKIiAIIUN. V . !{,. a oi,| ,,.,.,1 s. W;,s ;.(1miI 1^

■111 Miiy 17, l!ti:!. .sli,. WMs Milijcci to .•(.iisti|.;,ii..M. f'oi- iwriii V loin
li.Miissh.. liu.l suttcivdfrival iiMiii ill llic ;il..l(.iii.'n wil li rir.|ii,.iit v.iiiiil-
iiij;. NolliiiiM- liad pas.sed liy I he Ixiwcl. .sii^ locknl |. inched and v.i v

ill. puis.' Kill; telllllCliltUIV. IIMI ; IVspil ill iull>. L'4. KxailliMillh.ll

sliowcd a niovalilc incK'ular mass in ilic liyh' si<h' : i hi- iliac- l.issa
hclow fell ciiiply and was l.-nd.-r mi inrssiiiv. hul I In- alHliMniiial w.ill
was cvciywhcic sott. Kxainiiiatidii /»■,■ /cW/fm nmiMal. iiperal imi was
done Ihidu^'h the rij;lil ivi-liis (sc|>aral iciii <it liliivs). .ind a lart;e il.-o-
i-clic inliisstis.-cplioii reduced wilii surne dilli.-iilly ,-ill.-r ii had I.eeii
linmiilit oulside. ,\ hard InU n.n-sliaped paieh \va^ let! al I lie ape\.
.slie h'ft (III .May ltd. leeovery liaviiiu lieeii nnevenifui.

On .lune 1>,S slie reliirni-d tiom a cdii valexeiil Ikhik-. Nexl dav >lie
had abdoiiiiiial pain and voniiliii<; : the lii)wel> ailed i\vi(-e. Inil there

was no slime and lui Miiod in tlie iiiol ion-, .she <-a in ^iitVenni; from

iiiteiniitleiit attai'ks ol pain whi.-li caused her io roll ahoiil in lied ,-ind
cry out. 'I'lie al>domeli was rather disteii<h-d: n<i visil.Ie perislaUi .
<»n the lilllh the l.owels had no! aeled. alllioimh an eiieni.i ol glycerine
liad lieeii fiiveii. In tlie alteriloon the ol.l :,(-ai w.h leopein-d. The
small gut was eoiisiderahly di-leiideil. and there w.r, r-onie i-lear >eroii>
Huid ill tlie periloiieum. 'I'lie mesenteric ulaiids were l.-ir^'e. Tlie
iutilssUM-eplion was 2 Io :! lei-l aliove the ileoca-.-al valve and ahoiit
4 inches loiijr. It was easily reduced in p.-iil : the terminal j-ieec.
however, was much thiclvened aud comph-te reduction impossihle. linu

2<>.S

THR A( TTR ABDi^MEX

ill!

■ iiIIk sidiis cxtciKliiij; iH'twfcii llic itciiloncal siiilaccs. Tlic iiilcstiiial
rout cuts |iiissc(l ill is stM'lioii \vi li (lillii nil. v. I.ati'ral anastomosis aliovi-
ami IpcIow was pcrloiiiKMl. 'I'lic iiiiicoiis incnihrani- of the luiiii) looked
rather sjoujrli.v examined llironi;li one ot the iiK isioiis. There was no
evidence of I iiherele on examination and ap)ili('ation of von l'ir((iiet's
lest. She left the lios|)ital well .Inly 2().

Some months ialei- this i>at ienf returned foi symi>toms of olist ruction
due to sarcoui.i of a dilTeient pari of the small inteslini' (see |i. l',"(1').

A recurrence of the intussusception after complete reduction
lias ])een met with in more than one case, and to |)revcnt this
it has been reconnnended that the mesentery of the ileum near
to the valve should be shortened l)y the insertion of a con-
tinuous stitch. It so seldo;;. occurs that it is not advisable to
adopt it as part of the routine trcatiiu'iit.

The si'j)aration of a slou<.'h of the nuicous nicml)raiie may be
seen some days later in consetjuence of strangulation from
tight nipping. In the following case it came away about three
weeks after opi-ration, and. although there were some uneasy
symptoms complained of about three years later, there has not
been any proof of the formation of a stricture ot tin- bowel,
though such might be expected. The abdominal wall remained
j)erl'ect.

The i)atient was a l)oy .'5 years old, an only child, seen with Dr. ('o|ie-
laiid on April 20, I!tU8. Vomit iiifr had been jucseiit siiic(> the early
moriiinj; and there had heen complaint of ahdominal pain. The bowels
liad acted, hut no s|»(>cial attoiitioii had heeii i)aid to the ch.iracter of
the motion. Tiii'ie had been no blood or mucus passed. When seen
earlier in the day by J)r. Copeland there had been uolhiiifr abnormal
to be felt, and thi' tem])erature was about 10(( . not over. In the
evenini: when seen ajrain there was a swellinj; iu the iliac rcfjion. At
7 i>.m. there was a flattened, saiisajie-shapcd and somewhat tender
swellini: above the iliac fossa. The abdomen was i;enerally flaccid
elsewhere. Pulse. Hd.

The abdomen was o]iened al 8.4.") p.m. after dis))laci'meiit of the
rectus; and an ileo-cu'cal inlussuscejition reduced by manipulation.
'J"he teiininal inch of ileum and early ])art of the c:e<'i>m were (edematous
and thickened. He made a ^ood recovery, but three weeks later passed
a bi'oad bainllike circular slouj^h of the mucous membrane fioni the
lower ileum. The detachment olthe slouj;li was accompanied by some
abdominal pain and a rise of temperature in the morning of the day
on which it was passed.

With regard to tlie ])rngnosis in cases where there is
some sloughing of the iutu-ssusceptum a easu recorded in

OBSTHrCTION OF THK LAIKJK INrKS'llXK 2n!t

'■Holmes" System of Sur^'i'iy.' \\)\_ H.. p. y-jj. j, vciy
( iicdura^iiig :—

A Imy ol ."i iindrr llic care of |)r. nurklcy. (if Sniloii (iii'lrciil . |>M»fil
H iiiclics of llic ilfiiin, llic rirniiii willi its aiipfMilix. Mint alioul 4 iii<lii'>
of tlic colon, afliT an illnc-s of four niontlis' duiatioii. ami rn'ovcrcil
ill six wt'cks" linic. ^^ixlccii years later lie was repoileil a> having had
perfect health (liiriiii; the whole ot the iutei \ ciiiiiii lime.

Chronic intussusception is mostly met witli in ailults. and
is not int'rc([ucntly due to a orowth. Tlicse intussusceptions
being mostly irreducible, are usually treati'd by excision of the
alVected portion of the ))o\vel. the amomit removed depending
on the position and nature of any growth that may be present.
A removal of a wedge-shaped piece (f tlu' mesentery will lie
'icccssary if the tumoiu' is malignant, liider no ( ircumstiinccs
slwaild an attemi)t at a complete operation Ite made if acute
has been suj)eradded to chronic obstruction.

In those cases where a carcinomatous growth of the large
l)owcl lias been intussusccpted and proltipsed through the anus,
1 liave on three occasions excised the growth with succi'ss
so far as the immediate result of the operation was conccriu'd,
but one <;f them returned with general ili.ssemination in the
abdomen a few months later. The sphincter ani should be
dilated and the growth drawn well into view. The bowel well
above the growth, which is usually am lai in shape, should bi-
gradually divided with ^cissoi-s comple Ay round, forceps being
put on the edges as they arc cut. Silk sutures should then bi'
passed through buMi layers and tied from before backward-.
When the bowel is released it readily passes up into the upper
part of the rectum. The objecMon to this oj)cration is tlu- fact
that very few gland.s can be removi'd. The prolapse of itself
mdicates that there cannot be vi'ry much infiltration in the
mesentery or great enlargenu'nt of the glands. There is usually
some, b it much of it m; - .secondary to a sloughy sttite of

the growth, which is not unconunon, and often associati-d with
lia.*morrhage. The distress which it causes occasionally renders
operative interference an urgent matter.

OBSTRUCTION OK THE LARGE IXTESTIXE.

Tn this; section it i^ ni cos-^ary to include a consideration of
the forms of obstruction which are of a chronic nature, because

TIIK \( ri'K AIJDO.MK.N

))i<' |)i<'K'iitii>ii (if ill) iicutc ;in:l ntlcM ;! attack >li()iil(l lie

|i()s>il)lc it' till- coiidiliini is rccnuniscd time. It is far ton
cDniinnii to tiii'l that for a lout; tiiin- llir patient lias had
disconiforl and troiilili'>omc con'tiiialion foi' whicli various
foinis of |iiir;:atioii haxc Im'cii tiifd, and succccdi'd. more or
less iniiM'rffctly. in L'ivini; rchcf. then a coniidi'tc ohstructioii
has siipcrvtucil whic'i the most luTscvcriii;.' and injudicious
attempts at forcing; a pa ssajic have failed t(» overcome. J)urin^'
the years I'.MCi 12 inclusivi'. tliere were 121 case^ under
treatment in St. Thoma-'s I[o>pitiil in whicli a carcitx inatous
<;r(>\vth of the larjre bowel was present in acute ohst "uction.
and of these 70 died and '^\ recovered. .\cute ohstniction
was produced in Mothers by the pressure of maliiiiiant urov. ths,
i! I of these nine died. .\ case of carcinoma of the jejunum
also |)ro\('d fatal.

The causes of death in the cases of malijinant obstruction
fri'atcii by colostomy are sujumed up as follows by .Mr.
Rou(piette : —

Death due to ()|)eration. 21 percent. : peritonitis, !t percent. ;
pneumonia. 12 per cent.

Death (hie to |)rolon}icd obstruction. 7!t per cent. : toxa-mia,
(>7 per cent. ; perforation of growth or stercoral ulcer. 12 per
cent.

This is a large i)erccntago of fatal cases to be found in any
series of diseases of the l)owel at the present day which if
recognised early are i(uite ameiiab! to surgical treatment. It
must be conceded that the subjects of malignant growth of the
large bowel are often advanced in years, and may be sufering
from bronchitis or some other complication : but with the
inevitable ending which awiits delay, it would often hv the
wisest course to take the smaller risk and sul)niit to a palliative
operation sucli as that of lateral anastomosis, if on explor. lion
more curative procedures are not ])o,ssible. Jt is very sail to
find a patient sutfering from an obstruction of some two to
three weeks" duration, caused by a ring carcinoma of the colon
which is (piite opcral)le. and have (k'ath follow a colostomy,
becausi' the pati>'nt is already jioisoned by al)sor})tion from the
(iistended bowel al)ovc the ()l)structioii or exhausted by
vomitintr, pain and want of food. Even the causes of death
which are put ilown to surgical interference are in most the

()I{STin( TKtN OF I'lIK I..\I{(;K INrKSTINK 271

rt'MlIt lit cliailiics in lllr lioucl due In piolnllu'c;! nl»>lnuti(ill.
JU\il tllC |lll('llhli)IUM. a ('(ilM|llii'<lti<)|| (if lllr illlii'Nl llct ir ill .'III

cxliiiuslcd patient alrcaly MifTi riiiL' friim liypo^talic ( unt/olion
of tlir liiii^'>.

'riic majority iif tlu- cases of eaneer df llie intestine oeeiir
hetwten 4i» and (!."> years of a<ie. but it has l>een met with ([iiite
I'arly in life. Nothna<iel eolleete 1 til rases the aszes of which
were between lM» and :{0 years, and nieiitiniis others in which
it was found at ."{. ."i.l. II. 12 and li! years of a-^e. The yonnuesl
piilient in my own series was a lioy of If, in whom it was
necessary to perform colostomy for a lixcl ami extensive
carcinoma of the pelvic colon. .M;iydl says that one-se\cnth
of the cases are met with before o" x'ears of aye.

Of the cases in our jicneral scries from the hospital the
majority were males ; of a series of lol in the l.,oiidoii flos[)ital
(Jo were men ami sti women (iJarnard).

Tlic situation of the carciiiorua is important and in a l;ir;ie
series of cases was as follows, when it arose below the stomach

Itiillianl ;

1... II. inn ||n,|.ll,,l,
I'.MHI- I'lil",

Notluia;;.!:

Vit'iilia .
St. 'I'll aSsl|..r.|.iIal,

I'.iiti i:.|J(iiicl.) ,

•r..tai..'i(.;.

I 4 J

rntcliinii;; ai'ut.- iil.>trni-li..ip .,iiU'.

II" ■_"' II -Jll w

With reference to the nialigiiaiicy of carcinoma of the larjic
intestine, it is recognised that secondary deposits occur less
frc(|ucntly than in cancer elsewhere. The outlook in earlv
excision is therefore more hopeful. When it does occjr it is
commonly in either glands ,ir liver, but varies somewhat
according to the exact nature of the growth.

A cancer of the h.rge bowel may remain apparently without
change for many months. A surgeon to one of our large
hospitals told iric of a case of carcinoma of the rectum for which
he was consulted owing to an attack of obstruction which was

THK A( I'TE ABDOMKN

' i

rt'licvt'd l)y castor oil. Kijilit vciirs latiT Ihr patiiiit \Vii> still
uli\<' iiiul (lid not ;i|)i)car to siitYcr cxccptiiii; from an o((a>ioiial
difficulty wifli fl'c liowcis wliicli " liis inc<li(iiic "' always
relieved. I can recollect the I'asc of a woman of 40 w tio was
treated for obstruction due to a rin^ carcinoma of tlie siumoid.
J^umbar colostomy was performed and gave relief for several
years. 1 saw lier myself si.x years later, when the growth was
a- liming large dimensi' iis. This was in the days of lumbar
colostomy, before excision was practised.

The early symptonis of the presence of a malignant growth
of the large intestine are not very decided : they may consist
of a loss of strength, anorexia, lassitude abdominal unea.-<iness,
loss of flesh, and increasing pallor.

In the early stages j)ain varies very much, but it is not often
a cause of much distress until obstruction has begun or ])eri-
tonitis complicates the case. In the small ir*estine. transverse
colon, and sigmoid it is referred to the umbilicus : whei\ in the
more fixed [nots of the bowel it is at the point of fixation. If
there is an iiK rease of pain when food is taken the growth may
l)e in the lower ileum or ca'cum. Many parts are not accessil)h'
to palpation, and in fat people even a large growih may ]>e
difficult to finil, whilst a contracted rectus may conceal it.
There may be more than one tumour felt in the line of the colon,
making the diagnosis difficult ; under these circunvstances a
I)urge will get rid of the scybala, and the growth can then be
demonstrated. In shape and size these cancerous growths
vary very much ; if there is a large growth without any
obstruction there may be a colloid change, a solid cylinder
being formed without much, if any. contraction.

Blood, mucus, and pus may be found in tlve fa'ces if ulcera-
tion is present.

Occasionally a growth can be felt above the finger on cxamina-
fion [ler rectum, which from its mobility gives the impression
that it is operable, but it is necessary to give a cautious opinion
before examination from above has been done. Quite recently
two patients have been umler my care ; in the male it was
found at operation that the growth which had been felt was a
carcinomatous dej)osit secondary to a stricture of the same
nature higher up. and there were many secondary deposits in
peritoneum and bowel wall witiiout obstruction. In the

Ir"'

uiJsri'jf iiox (tF Till-: h\i;<iK iMKsriNK jT.t

fi'iimlc. wlio lin 1 siilTcn-:! trmu .ilidomitial p.iiii aii'l iiir^iil.u'' y
of tlic l»()\\t'U uitli xtmi- lo^s of tloli. the tiiiiuiiir' v\,t- :i mull
i)\ai'iiiii lysl w hicli was allicnnf to thf trout nt the iictiini in
J)oiijilass poiifli.

SoiiU'liiiics flu- X-rays trivf <irvs\t a>si>taiicf in tlu> ilia_Mio>i>
of tlicsc I'oiulitioiis when the liinim of tlic houil i> iiairownl
l)iit ol)striU'lioii is not complctr. A rarciiioiuatoiis iirowili
coiitiinics to contract an^l the syin|»tiini- associate I \\ith
chronic ol»-triictioii a|»|)('ar sooner or later.

There is a coni|)hiiiit of increasing con-ti|>ation w hieli
ordinary pur^'ativcs (h) not appear to icheve : indec;!. they
cause |)ain. I'lneinata are then trii'd and fail after a tune.
There are attacks of diarrhd-ii wliieli aiter'iate with the con>tipa-
tion. (irow ths in the lower colon may cause ainio-t continuons
looseiu'ss of the bowels ; sometiini's an alteration in the shape
of tlu- motions. Kxamiiiation of the al)domen will often show
a spasmodic contraction of the howcl above an obstruction, or
abnormal thicUeniiiii of its walls. This is found at or abo\c
the rejiion to which the pain is referred. I.,ater this l»ecomes
nutre extensive, and friction of the surface will excite painful
peristalsis. Attacks of colic may conn on with vomit in;:,
runil)lin^ of wind, and distension, la lead-colic and enteritis
intestinal coils aic not visible.

Continued distension of tin- abdomen follows when the
obstruction is complete or ahnost so. and is greater the hiwcr
down the obstruction is placi'd : it may increase until the w hole
a}»domeii is rounded and balloon-like, the distended intestine,
both .small and lar^'c. lill:n<i; the peritoneal cavity and even
pushing forward the ribs and eiisiform cartilage. There will
tlu'n })(• a general tympanitic note with jjci'liajis a dulness in th
Hanks from the fluid fa'ces in the colon, whilst the superficial
veins show up dearly in the stretched skin. I have seen some
ca.ses wln(di had taki'ii four to six weeks to get into this >tate
and were still not much trou})le(l by either vomiting or pain.
.Many of our hospital cases have l)een "" worse " about three
weeks: The first week, paroxysmal pain witii wind and
oonstij ation ; second week, constipation, vomiting. di-t(>nsion,
pain ; third week, incroaseil pain, greater distension, with
otionsivo vomiting, dry tongue, hiccough, thirst, and rapid
eniaciatiou.

A.A. T

271

iMK Aciri. ,\iU)().Mi:.\

Oicjisidii.illy ii ii.itiint wlm was • duinu nicely" p'fs jiiiitc
liloiLiim <>t till' ••.iiciiioniiitnii-. >tri(liirc tnnii a torcij^'n l»o(l\. a
fa'ciil liiinp. or miiiic (ifln r cniMplii'aliun. ami there i> a rapid
<le\elnpiiieiil <if nrjieiif >yiiipti.m>. The pain i^ inure xvere
and eontiiniuns with e\aeerl>alit>n>. the vmnitiim i~ di-tr"»inji
and the vomit changes its e'laraeter. Iieeoniini: teenlent.
N'olhin;; is pa»e>l li\ the Iiowei. and '! eneniata tail to hrinji
away any t, <ii matter or wind: i he disiensinn increases
rapidly an-l at last the .s,.|,j,|-at(. coils • inilistiiii.'nishal>le.
Shonli perforation now o^'cnr. or peritonitis arise from some
other caiisi'. tenderness and rigidity will he manitested. and
there may he a temporary rise of tempt ratn.-c wit'i a rapid t'ailine
in the strcniith ot the pnlsc. The patient ))ceome,s co||aps<d.
covered with cold swciit. the hands and t'cct arc cold, pain
ceases, the pulscdics away, and forsomc hours licfin'c death mav
cease alto.uet her. 'i'he lirealh even^'ivcs a (-(dd sensation to
the hand, a (piantity of foni lliiid is Derhaps ixmreil from the
mouth, and the end comes >(> suddenly that the friends, who
are perhaps talkiniiwitli the patient, arc (piite iinitrepared tor it.

In the dia'inosis of the cause of <)l>striiction of the larjic
intestine, besides cancerous j:rowtli there aie various oth<'i
coiidit.oiis which must lie considered, the chief of which are : -

(1) Ka'cal impaction, distinguished from trrowth 1)y the
result of rectal examination and eneniata.

(!') Ilco-ca'cal tuhcrculosis ; ( ,n often only l»c *old by a
iui( 'oscopical examination after removal.

(!) iMU'eifiii liodics. such as concri'ti<ins and jiall-stoncs. have
l)ccn mistaken for jirowths until operation.

(1) Si<?moi(litis. with thickcninir ahout the b-wvel secondary
to the development of a |»ouch in the wall of the howcl. is more
common than is ifcnerally ])clievetl.

(.")) Tumours of neijihbouring organs, siu ii as —

A. The stomach.

Oil I'cliniaiy ;{. inU. I opcialcd '. i Dr. Mackenzie on ji casp ol
tiiiiKiiiv of liic aliiloiucii wliich was rc^ii'di^d as one of ^'lowlli of 1 he
il. -I'oiKlin;;- nildii. ll was tlic size of a clt cd list, on the left side liclow
liif level of Ihc iiiiiliilicus. tender and adlieieiil lo tlie ahiloininal wall.
'I'liere were no sloniadi syiiiptoins. and free liydrocliloric and tiee lactic
a<'ids wei<' iirescnt in the jiastiic coiileiils.

( 'nMoiolu.v a.id -i'ji.iiiiiiun III ilir .sw'ciiiiij; fnuii ilic jjaririal pri iiiiiii-iiiii
enabled us to eNancMc it ihoroiiglily. it wa.-> Iviim to tlic outer side ot

oBSTiUf rroN OF TICK i.\|{i;k inikstim.;

Ii.. ilfxTlidllli: roliiii. Iilll \\,i» III Ihr 'iiiil.irli, li,i\i|ji; .himm III \ir
I'lcaln riirv.iliiiv. iiml lli.rc wciv iii,im\ ciiluii;..! mimI mI.v nm-lv
liialiKiiaiit uljiiiilo III ar.

H. ' II-l>l;i:lilcr. A h.ir.l |iiiiiiful ^wclliny Jn ih,. fj,_rl|| iij .,.
fossil, tlir DUllinc of which was not tM-ily .Iriim "i in an :'v.i-i\
liidy with coiisJipation. pnivci to Itr a ili~iii !<• I i^all-l.la'lilcr
coiitaiiiiii^i iiifuiy stones.

V. I'tcrus aiiil <ivarifs. .AfaliiriiUMt L'touth- ha\iii'_' their
orijiin ill these or^ians may inva'ie the hou, I, aini \ iihoiit
operation it may not l.e possihic to(li>.iin;ini-h them. Tahiative
measures only would he po->ili|(..

Ill eases of oh>triielioii due to a ;.'routh in the lari.'e intotine
il is a ivisahle to operate as smou as you ean. Do not uail for
the onset of vomitin;; and di-teii^ioii ; an earl\ npe.-iiinn :iia\
jiive the patient a eliauee of cure. I ■|ifortuiiiilel_\ il i, mil
|)ossil»le to sa\ . iiiitil the ;;ro\\tli has lieeii seen, if it uiil he
possible to remove it. \\>u will, nowever, lia.ve no rea'-on for
self-reproach if this is so. and may hi able to save the jiatient
much pain and sutTerin^' l>y pt iforniiii;.' a -liort -circuit operation.
It cannot be too fre(|uenll, repeate I that anylhiiiL' like an
attempt at immediate removal of the ;.'rowth an I the tormation
of an anastomosis when obstruction is present is certain to
prove fatal. The jiatient's friends should be warned of the
necessity of doing the operf.'ion in two stages Manv live- a;v
still beinj; lost in consei|uenee of iiei_'lect of this rule.

V "i a patient comes f.ir relief with a «ireatly di>lended
abdomen, and the |)ositioii of theoi structiiiu caii>e i> unknown,
the liest plan is to make an incision to one >ide of the middle
lii\e, open the rectus sheath, and displace tlie muscle outwards.
A distended coil will present itself ami ■ bouid be drawn to the
sur.'ace, precautions taken to prevent soilinji "f the wound
or peritoiH'um. and the C(;il emptieil tli'-oii;.r|i a |)unclure or
small incision, .\fter this coil is emptied of (;as and lliiid
contents anothei sliould !);■ taken and treated in a, similai
manner, and a thinl or fourth if neccss.try. Kacli puncture is
closed with a purse-.st ring suture, the coil c Mised .md i tiimed.
By this means tlie distension is niiicl- diminished and tlie
pres.suro on the diaphragm greatly :-elieved. Il i< mw possible
to pa^^ the luuid into the alr:!i)mi;:al •a\i!_\ a, id k arn tiie
position ot the growth aiul its coimections, also the iiresence or

t2

liiti

m

li^

J7(i

TIIK ,\( I TK \I5IM).MKN

iihsi'iu'i' (tf >cciii>iliir\ urowtliN in tlic liver. ulainU or |mi ilniKiiiii.
Tliis is iin|)(>rtiiiit. On iiHiri- tliaii oiif occiwinii | lia\( fMimd mi
(i|Mrahlf linnvth in tin- intisfinc with a Imrt history of nhsf ruc-
tion ami a larjjr sccdudary ur"^Mli in the liver. It th' re i> a,
fixed yrnw f h in the sigmoid nr peh ii- culon. and if i> not po^^iliK)
to do H short eirctiitinu o|M'rittion, colostomy diould lie done
on the lett side in th ■ tisual position aii<l a I'auls tiihe |int in
the l)o\vel where it comes easily to the sintaee. .\ similar
operation is re(piired it' there is a ti.\ed i/rowlh in the reelina,
hilt as a rule he nctal growths are found h tcire opi ration and
the exploratory iiui-iou is not needed. In the |»irtorman(i' of
colostomy for the relief of ohstrin lion I am stron;;ly in favour
of the completion of t lie operation at the lime. In thi> way
r<'lief is alTorded at once, and exj)ericnce convinces me that it
IH (piite safe.

M.iny Vciirs U).'o I I'liiiuiielii'i'tl :i rulosliiiny iit Mic ilnv.il I'rcf l|iM|iiliil
iiir oliHiriiclioii tluc lo I'airiiiniii^i. in tlir |>i'lvi>. TIh' jiaiii'iil was a
woiiiun in contl cuiKlilioii alul tlie iili.>trui'i ion iliil iml apprar very
iii'Ki'iil. 'I'ih' niloii wuH .sntiirctl to tlie wounil iratl.v lor o|irniiit; latei'.
'I'wo (lays attt'i'Wiirils tlic paMfiit ilieil siiiliti'iily ami we lounil llial llie
lliickrlii'd liat sottrni'il wall ol ijj)' l>owt'l liail licrn lUpliiieil aooM' lljt-
siitui'cil ]>i)ii l)y excessive niusnilar action. The ol>slruclion was
(•(Mupiele liul I he amount of disleiision not e\i'cssive.

Since I lial accjileiil occui led I have always plat'eil a I iil)c in an opening
in the liowei al once when operal in;j under similar circum>l ances,

The operation is j)erformed as follows ; — An incision of
;> to 4 indies, accordiiij^ to the thickness of the altdominal wall,
is made in the dii'c<tion of the librcs of the external <(})liipit —
tiiat is to say, at right anrjies to a line drawn from 'te left
anterior superior spine to the umbilicus. The exti-rnal ohliipio
is divided in the same direclion for the full length of the wound
and the fibres n-tracted (Kig. .'58). The internal oblique ami
transvorsalis are divide<l in the interval, which is in the centre of
the wimnd and is shown by the line of fat deposit between the
muscular fibres, which now extend at right angles to the incision.
This part of the wotind is also opened up with retractors and
the subperitoneal tissue shown. Incision throtigli thi.-', the
transversalis fascia, and the j)erit Mieum should l)e of limited
extent, according to the distension of the bowel to be brought
outside. The bnwe! is recognised hy its !on;iif udina! nniseular
bands and appendices epiploicse. To secure this in position, a

nIlS||M(ll<<\ OF THK \A\U'V. IN Ills IINK

luilp llf it i-4 <ll'il\\ II ll|l lllllil

till' liiiui" Mii'i lliiiinli ran in-

iiiii Ic lit liolil llic mi-i'iilriy

li yuiiil. A thick li^li-iit

■<iitun' is tliiii |i,i»-.ii a<iii-.-i

hum side tu -iilc (if tile

WiiUInl Ml tll.U ill'' iiiii|i ot (lie

liuwi'l i-i li\( i| well t»llt-i li-

witlioiit tiiisidii. This silt nil'

shoiihl }^o thl'iiii^'h lh> iik'^u-

foldii (ir iiifso siyiiiuiil ahniit

ii.li iiii'li ti'oin tlh' |ii)>trriiir

iiiai').'iii lit the ii)ii|). .iiiil it^

|»,i->ii'_'i- i- lacilit.ih li it fnrci')i>

arc |il,ii'cii nil tile |>critiiii"iiiii

at I he |i<iiiit> lie II- vvliicli it is

to |ii'iictr,iti'. Till • >hiiiilil

!»■ jiiit Ix'iow the iiiiiliil- III

the ii|ii'niii<r. thus Icaviiiii the

ioiijicr space for the innxiiiial

jiart of the !oo|)(Fiii. :$!•). 'I"\\">

silk sutures a.e passeij al)i>ve

ail'l Itcldu tile limp of bowel, wliidl illclinie lilllMle. perilollelim

an I the wall of the bowel itself. \W llifse sutures the size

llf the opening throiivih

which the liowel passes

is liiiiite I if necessary

ami an further |tro-

trusinii is piosible.

They are aUo a safe-

;^uar.l atr.iiiist fallin;; in

of the ^llt sllolllil tile

stitch throimhtiu' iiicso-

colon j^'ive as a re>iilt

of violent voinitiii<^. 1

lia\t neverseen it ilosii.

, , . Tc . . !■ ■ Otlier lislii'ut sutures

]• in. -KK ( iiliistniiiv. lliii;.'lain nt iiuss- '^

M'ltioii ut iiiiiiloiuinal lim-i- with are placed ill the wound

lixatioii Miturc li;iss..(l beloio tviii- ex- ;il),,vi. and below as

I'lii. 'Js. I.i ft lliiii iiil.i-toiiiy. Til.'

lilli' llf iljri-l'.n, witll I'.'tril tiiill
III (liviijril |.\tilll:ll iililii|Ui'. 'I'lle

arniM^'ciiiciil nf iiitiiiiitl ipMiiiue
tililos i.. ~liii\vii.

tWILtllv. 1. Al.l!..!M

tlUlwlK, [K'l'l-

tmicuiii mill -kill. '2. .Moii-i-nliiii.

reipiired. Tiierc is now

27S

TTTK ACITK ABDOMKN

it

ii <i()()(l-sizc(l liKipot Ik.wcI |»r()(ni(liiin : in onli-r to Dpcii this at
uiicciiiKl safely it is ciiciivlcil with a stri|»of <.'aii/.<". only the a|)cx
lifiiiLi ictt cxitosi'il. All atl("<niatc iiu-isioii is uiaiic in thi- tor
the insertion of the tnl)e. tiie knife goini; into the Innien of the
gut. any contents ))ein(r wiped jiway. Foreeps are now
phieed at fonr e(|ni(listant points on the wall of this incision
and a continuous stitch <if No. 2 silk ])asscd with a straight
round-bodied nee:lle. A small-sized Paul's tube is inserted,

! • 1 !

Fl(i. Id. r,,l,,stoliiy. 1. TIu'Imiw. 1
liiis liufii liroii;.'lit outsidi'and the
WKUiid cldsfd. 2. Jd'cp >\iturc
l>:is>iii;.' throii^di alijiiiiuiiiil wall
and liit'-iicdlnii. ;!. Line .it' iii-
.■isi.iiifcirtulic. I. .MuM'ularliaiid.

]'"Ui. -41. Coliistdiiiy. ( liieuiiif,' lield
liy Idi-ccjis tci t'acih'tate ]ia»iii;,' of
niiiuinj; tluoad and iiitrnjiictioii
(it t\ib". 'I'lio wiiuiid is inotccti'd
liy ^'aii/f, wliich is chaiij.'-i'd at'tor-
waid?!.

the .suture tied, drawing the edges of the bowel incision round
the tul)e beyond tlu' flange. The ends are ))assed round the
peritoneal aspect (.utside and beyond the forceps, again tieil,
and cut oif. Tiie l)owel and surrounding parts are cleansed,
and another strij) of gauze drawn round and round the loop of
bowel so that a thick layer protects the wound and at the same
time supj)()rts not onlv the tube but also the loop into which it
is inserted. A dressing of sterilised gauze, reinforced with a thick
layer of wool secured in position by a many -tailed bandage,
supports the parts. When the patient is in bed the thin rubber

1^^^

oBsriUM rioN (»K riiK laikik iniks'iink l'th

tii})c attiU-lu'd to tlic l*;uil'> till).' is pl.icMl ill .1 (•(.lucniciil iv(i)i-
tacl" liv liis side. ( >iic ctTccI dt the ciinilar -titili i- ti> ciii-c a
sloiiyli to t'oriii. and the tid)c (•oii!(> away in tour to -i\ days
after the oi>i'ralioii.

In all tlicsc rases it is advisable to cmiily llie >toiiia(li Aitli
a tube befoi'i' tlie operation and </\\r -alin.- alter\\ard> liy the
rectum. These patients are ohen
not only starved by their lon;^
abstinence from food, but dehy-
drated b_\ tlu' amount of lluid
which they liiive vomited and
been inia])le to replace. The
results of this opi'ration are very
satisfactory .

I iccfutly >,iw (.lanuiirv. I'.U h .i
WDiiiaii till wlmiu I ills o|iciMt inn w.i
<l(iiic lor iniiinMiililf rairiMimiii ol ilic
rrcHiiii. and siic >ii(>ki' iikim fiilliii>i-
n^lically of the licnctil uliicli ^lic
hml ■Icrivfd Iroiii it. ami llic Miiall
(liscdMitoil wliii-li ii causcil. She liail
Icaincd to iiianai;f liiT ailitiiaal amis
cxcfllcnlly (liiriiij; I ln' toar \cais
wliirii liad i'lai»cd since ii was inailf.
and ]»iffcned tlic aiii>ii<at ion "t a
pad and lintilai l>anda>ic In the naiii'
clalxiiatc a|>i>aialus witli whiili slic
had Ix'Cli sii|)l>licd. She wcl 1 atxMii
as usual l>i>tii "11 tool and in pulvlic
coiivi'vani'cs.

I'll.. IJ.— I'olii-tniiiy. Ci.niiil'ti.iii

111' llpt'l-.itinll. 'I'lll' strip ol
j;aii/i' i(iViT~ juiictiiih of tnlo
liiiil l.iiwrl: it al-n c.iM'is
till' woiniil ill aliilniiiiiial wall
and till' u'ut at its riuL'i^iaii'.

Manv surgeons arc in fav(nw
of Paul's method of treat miait
of a malignant strictiu'c I the
bowel when it can ))e brought to

the surface, whether then- arc secondary giowths or not. and
there is much to be said for it. By this ojieiation the growth
is l>rouglit outside, and either

(1) Fixed with the loop in which it i> growing in the woinid.
a Paul's tul)c l)eing put into the upper limb. Heri' the growth
is removed later, or

(2) The gn)wtli i.s brought outside and cut away. .\ Paul s
tube i.s then fixed in each end. These ends are suture I to.ctl'.i r

iiM

li '■V

•S(l

Tin-: ACUTE ABDOAFKX

iii.d lixcl ii, 11,,. wound. Kvcn if tlu'iv iiiv sc-ondarv growths.
rcMKival (.1 the piiinai y one will probably piolony lif,'a,id inal«'

the futun' less liabj,. (,,
painful coniplicatioiis. Xo
attempt is hen- made to
restore the intejrrity of tjie
eaiiai. and there ean be ))ul
inade(Hiate removal of the
jilands in the second method.
It is re<{anled as an opera -
t ion rather more perfect than
a simple colostomy.

The t\\()-stai;e operati(»n is
often advisable when it is
})ossible to perform a lateral
anastomosis in eases where
it is not good surgeiy to
excise a growth. The wall
of the bowel above, anil
often for some distance
above, is so ill-fitted to hold
sutures that they not infre-
(lueiitly give, and the patient
dies from peritonitis.

Ill the same way ileo-

colostoiuy )uay a])pear indi-

].:itenilAnu>.t(iiiiosis. 1. Large eated in a case, but the

• cL:;::ir:;:r\h?''i;::;: --i;tiou of the disteu,.ed

.small bowel with its softened
wall will show how dangerous
such a j>rocedure would be
until things have settled
down.

Should, however, the ob-

bi p\V(

lll-'OIl ^

iipiiioxiiiiatc'd. ;j. The posU.rii.rcon-
1iiniou.s seni-iuu>ciilar sutiiiv lias
been cuniiletnl. l. luci>i,,ns in back
l>oiti()iis ,,f b„wcl. 5. Tiio ends oi
the futures are held bv ark'rv
|nivei.s. (i. Gauze lias been idaceil
behin.l the parts enga-.'d in the
aiiastuninsis, and stnietures around.

struct ion be .•<nbacute after
a more acute attack, the former operation niav be done
as follows ; —

The portions of bowel to be united are brought outside and
isolated b means of gauze strips. They are then placed side
by side and clamps put upon them in such a way that there is

()HSTl{r( riOX OK TUK LAIJCK INrKS'llXK -Jsl

H suniciciK\\' <>t Ix'UfI isolate, I uii cacli siilc to |»(iinit ol a com-
imiiiicatioii of ahout '.l iiiclics l)cini^ cstablislicd. A (■oiitiiiiioiis
silk suture is tlien iiiseited eoninie.ieinu al)o\e ami ineludiML;
tiic serous, museular. and i)art of the sulniuieoiis euats. The
end of this suture is plaei'd
in aitei'v forceps, and \\ hen
it has been eouipleted the
needle is placed in gau/.e.
or into one of tiie sterilised
cloths, luitil aijain Avanti-il.
This line of suture should
be about [ inch from the
])art of the bowel most
distant from the mesi-ntery.
The intestine on each side
in turn is now ini'ised ii\ a
straight lini' in fiont of this
suture (Fig. 4:j). The two
incisions, being p; rallel. are
carried down to the mucous
meml)rane from which the
outer coats have receded ;
scissors arc iu)w used to
open the bowel and cut
away the ellips*^ of mucous
membrane which is ex-
posed. The parts of the
bowel beyontl the clam))s
are cleansed carefully with
saline anil gauze swabs
helil at the cud of
force|)s. These forcejjs are
again placed in the sti-ri-
liser. A w hipping suture in-

l''l(i. -H.— l-atcnul Aiiii>t..iMn>i-^. Tlic

lMl>1l'linl- Jiart lit' nlltl'l' MltUl'O ciPlll-
]>li't('(l. tlu' liiiwi'l iiliciuii;.'> iriuilc, .irnl
the imiui' MituiT CHiiiiiit'iiccil. 'I'hc
nt'i'dli' j)iissi.'< tliicnii,'li all the ciiat-,
which aio held t'lijcthiT with torcc|i-..
1. I.arp' bowel. li. Small liowel.
;>. ' 'Iami>s. 4. Outer i-.)iitiini()U>
MitMre. o. Inner etnitiniKms >uture.
(p. I'drcelis liolilinjr tli<' riiat> nl' hutli
]iurtiuns of bciwel in l"i>itiiin. 7.
< uiu/.e.

eluding all the coats is then
inserted, and it is a great help in doing this if the peritoneal
surfaces are kept in apj)osition by forceps (Fig. 44). Much
help is also afforded in the suturing if the needli', pa.s.sed across
the two opposed walls of the ))ouel. is grasped with forceps l)y
the assistant, who holds it until vou can take it. and keei)s with

2S2

TIIH MVTK ABDO.MKX

i III

i;.i

liis other liand the tliroiul at tin- rijilit dcjiK c of tension. This
inner threail is passed through all tiie coats, at its eoinnience-
meiit al)oiit | inch from tiie end of tlie incisions and ticil out-
side, tlie end being placed in force})s. It is continued circuhirly

round the opei\ing until tlie
edges liave bein l)rouglit
together, when it is tied to
tlie end held by ti.e ])air of
forcej)s. .\s the thread conies
round to the front it is not
difficult to continue it with
the left hand. The clamps
are now removed <ind the
])arts washed with sterilised
saline. if the gloves are
soiled they should be changed
and fresh gauze packed round.
-\' y bleetling point in the
edge can be ligatured. The
needle of the first thread is
now taker and the outer
suture continued in a manner
similar to that which was
done behind and at the same
distance fnmi the inner
suture (Fig. 45). The ends are
tied, cut short, and the junc-
tion is effected. If there is
any doubt about the security
of the suturing, extra sutures
should be inserted at the
ends to bring more of the
peritoneum together in the
long axis.

l''l(i. i'). — l,;itoiul Aiiasti)iii(isis. Tlio
outer contiiiUdiis siitiin; iiliriost
L'oiniik'tcd. If tlu'if is any fi'iisinn
tlie cliiinii^ may In- ivuKived lit'fnri'
tliis jKirt of the sutuvt' is coii-
tiiHicil. 1. Lary:e bowol. 2. Smull
bowel. ;i. (/laiiij). J. Inner
suture. /). Outer suture, to be
tied tu (i, which is left long foi
this purjio-'^e. 7. fiau/e.

This anastomosis mast not
be too close to the growth, there nmst be no dragging on the
line of sutures, anil the two portions brought together shoukl
be isoperistaltic. Shoukl it b( considered best to make a
short circuit })ttwcen the ileum and large bowel, the same
method bv lateral anastomosis mav be used or the end of the

OBSTRTTTIOX OF TTIK LAHCU-: INrKS'l'INK l's;{

(lividctl small inlcstiiif inay 1)" iiiscrff(l iiiti) the laii:r Ixiwcl,
the ilistal end hciiifi closed with a doiiliic layer df Miliins and
dropped. Tlic portion of lariie Ixiwcl selected is i olaled with
a ilaiiip as it is in lateral anastoMKisis. and the fi'ee end oi' the
ileum which ))ro)t'cts beyond another intestinal clam|i treated
as follows : —

After thnr()U<;li cleansing', the lirst outer suture is put in.
taking up all the coats to the sui)nnicous layei' : tliis hciiins
above Jiboiit } inch from
the open mouth oi the
small bowel. An in-
cision of leiiiith corre-
sponding to the open
mouth is made in the
side of the large bowel
and a running thread
carried rounil to unite
all the coats and act
as a ha'mostatic suture
(Fig. 4()). After removal
of the clamp and clcaiis-
ing of the parts the lirst
suture is then continued
round the line of anasto-
mosis at the same dis-
tance from the com-
])leted inner suture.
This union should also
be without tension.

Ill order to give an
aged patient relief for a distant journey when much distended
I have punctured the transverse colon and given e.xit to
enough gas to enable him to travel to his home in ccmiparative
comfort. He was a man who refused any other operative
help.

Volvulus is the most common cause of acute obstruction of
the large bowel, and is found in the sigmoid llexure. and at tiie
ileo-ca^cal junction. t)f these the former is tlie ni<jre conunnn
and the patients mostly men.

The attack begins suddenly ; i)ain is severe and often

Fn

tion
side.

llfn-c(ili]>ti>iiiy. A. Imiilaiitii-
if the >iiiall iiiti'stiiic, ciiii to
Tlic i)()>t('riiir i):iit of the oiiti-r
t-imtitmniis suturi', iiiiitinj,' tln' ]ii'ri-
tiiMi'iil anil iiuisciilar layers, lias lucii
iiisi'l'tt'd and tln' incisiim niailc into
till' lai;;<' Imwcl. 'I'hc rlaiiijis aie
nut >hi)\vii. 1. Ili'uni. 2. <'iilnn.

u

liu.

il--

.'SI

'I'liK ACITK \]U)()MK\

|);u()xysiiial ; Iciiilcrncss iii)|)r;ir.s (|uitf early. Ndiiiiliiiji is nut
I'l^iijilly a symptom wliicli ••luiscs ilistrcss. iiiul may cvt'ii !»c
al)s(iit. Distension ot tlie aliilomen eomes on witii eon.sidcraliie
rapidity, and the respiration (piiekly beeomes emharrassed
in eonsecpience of pressinc on the diaplinitim. The involved
))ortion of tile howci tends to heconie i;iniiirenous in a few
Ikjiu's, and peritoniti'- (as inditaied l)y the marked tenderness)

is an early eomplieation. As a
rnle no separate coil of gut ean
l)e distini^uished. When the
ileo-eu'eai rej.'it)n is affected the
symptoms are of less urgency ;
here there may he a resonant
tumour of consideraLle size.
N'omitinir is })resent. l)ut not
usually of urgent character.

Without early operation the
j)rogn()sis is very grave. \'cry
often the coil atfecti^d is gan-
grenous and resection is indi-
cated. If the patient is very
had. the gangri'nous bowel is

^ , ,„ .,., drawn out of the abdonu-n and

1m,w<1 hus l.ocn insert. ,1. Tho a pauPs tube put in. Later
oiiils (pt buth inner anil (inter ,. , . ,

sutures are left h.n-, so tliat ^'"^' g'">J^n'n()us ])art IS resected
they may be contiiiuid and and tho l)owel restored bv an
ultimately tied ut A. 1. Jleuni. , ., i i i i . i " ,

o Colon. ciul-to-end or hitcral anasto-

mosis.
Kk<i 1!1!i;nt Voi.vri.is ok rFn; SeMmi) (Kiilerostoiny : Ke-
covery). — .Mr. I!., ajifd 7(i. was seen with Dr. \. K. (lodtrey on
-March 22, 1!)14. lor iiUeslinal ohstruelioii.

'I'lic ])resont attack commenced with colicky ahdomiiial pain and
constiiia'ion ten davs licfore. Hiil haviny had some liv(> oi' si\ similar
attacks during' the i)revions live years which had yiehh'd to treatmeiil,
lie had rather pul otf calliiiji in medical aid. At lirst lliere had liecn a
certain amounl of relief from the use of remedies to act ou the liowel.s,
and cucmata had lieeii i)arlly successful, but gradually the distension
had liecomeexiremi- and 1 he pain paroxysmal, whilst little hut coloured
waler could he washed from the howel.

The ahdomeu was much distended, and tlie distension was most
marked on the left side, where there was a hu'^c coil of the lar>;e intestine
which coiitr.'ictedsjiasniodically duiinsr tlieexamilialiou. The ahdonien
was re.-oiiaut all over (very t ympanit ic in front ), but not tender. Kectal

Fic. IT. lleo-CHl,,>t(.iuy. It. Th(
]io>terior part of the inner suture
I'licirclinj,'- all tho coiits of tin

OBSTIUCTIOX ol" TIIK LAIiCK IN'l'KS TINK js:,

cXilinillniiiill \\M^ lir;i;i! i\f. He was mil siik. AUi[ \\a^ .iMc lo lake
tlui<l tdixl. I'ulx'. IiMi; arlfiif. rather liaitl ; imuiii' liincil : iml
tMiiiit'iutrd,

npcratiiiii |iiriiiii icil on llic 24lh. An iiici^ioii xva- maili' lo tlif 'ill
i>f tile iiiitldlf line, llif viTlus displaced mil waitls. and llic |Mt ildiiiiitii
opt'iicd. A very larjlf foil oi larj.'"' iiilfslinc |>ri'>fiilid il-ill. >ii laii;c
llial wlii'ii oulsidi' liic alidorncn il iiira^iiu'd S iiirhis lo !t iiiclii^ ui
diaiiiflfi-. This was cmiitifd ot a very lame ariiouiil ol i;as l>y a -l.ili
woinnl wil h i •■ itoint ol a scal|><'l, 1 liric liriiii.' only a It'w ilro|kN ol llwid
ill lln' ho we I. Allcr flosuic ol I Ills ci|icniiii.' wii II a slilrii il wa- ini>>ilili'
to <-\aiiiiiic llic iiilciior III iIk' ahiionn'ii niovc liilly and hiiiii; iiHirc ol
Mir siy;iiioid oiilsidc. Il wa- llirii ((uiii- cvidi'iil I hat i he oh- n ml ion
fid lowed a vol Villus ot 1 lie si;;iiioid. liicre lieinu a eiiiiiplele linn of a lnop
from Icfl lo ri^lil . Ilie poinl ot lolal ion heini; al llie level ot 1 he |iroimin-
tory of I 111' saeriiin. 'The inesosioinnid wa- viTV Iniii;- ami I he hnwel
wall tliii'keiied and hypeil miihied Winn lhis|iaH of llie j,'m1 had heeii
elii|ilieil the iipper ahdonieii lonked i|iiite eoiieave, iUid alilioiiLfh llie
small intestine was soniewlial distended, ii was quite remarkahle Imw
Veiy lillle fiei'al matter was seen and how lilt le ditVeieliee lo the i;eneial
distiiision iiad heeii eonliilniled hy the small linwel. A inlie was
jdaeed in th<' sigmoid helow l he middle nt t he loop, and 1 lii^ was seemed

ill the upiier end nt 1 he wound. I'liiTe was i viii.iice of mow 111 w liieli

the recent history of ihe ease had sii",!.' -ted hefoie operation. The
want ot eeilainiy made it ad visa hie to exiilore hehiie opening l he lai <ie
>;iit.as is usually done in liie olistiueted sie;inoid when Iheie i- not
11 malit'ualit stiieliiie lo he felt. Me did well after the opeiatinn. and il
was not loiij; before the liiiwcls acted iial iirally. The f.-ecul listula was
very useful for .some diiyis, and the altachnieMl of the larjte howel at
that pjiiit will inovoiit a return of the volvulus.

PART VII

if ■

Ma

I t

(0X(;K\IT.\L J)lVERTI(rLrM of THK CV.STIC DUfT

I.N coiisidciiiig lluctimtiiig swfllings in the Mihlicpiifio region,
whether ahseesse^ or snijpurating hychitids. there is a eonditioii
to bo referred to whieh. although very rare, closely resembles
them. It is that of congenital divertieulum of" the cystic
duct. The remarkable charncters which this disease 'may
assume is shown by the case described.

F. (i.. 11 jiiH jijrtMl 14. was admittod -X- „„ Julv 10 ami dicl
Novt'tiilxT 14. I!»(i7.

She had hc.Mi healthy until u mouth hcUnv. wlicu sli,. l,,.jr„„ to
i'ouiplain of i .ins iu the rijilit side with vouiitiiiK. For Hve davs tlie
paiu li.id lieeu coutiuuous and nioi'e severe.

\ tlnetuatiui:, proiuin.'ut. vouuded. verv tender sw.-llin.r was prosent
on the rijrht siih- below the liver, not nioviu.i; well with res"piratiou and
Its outhne towards the miildle line was ohseured hv rijridity ol the reetns
muscle. The swelling; passed backwards towards the ruinhar re^riou.
Ilerp'ise was 110; respiration :ifi ; temperature. I(i;{.2-. The ton;!iu<
was lurred iind bowels eoufincd. There was iu> iaundice.

An incision was lirst made iu the loin and the perit.meiuu oi)ei.ed ■
the sweliiu;; was found to be covered with peritoiuMim and attacluMl
to the under surface of the liver. .V secc.nd incision was made
m front throufrh the rijtht rectus. Throujth this the cvst was ta])ped
and :Ui oz. of thick green bile drawn off. The wall of the cyst was very
thick, especially the linin};. which was wliite in colour". Tlio galf-
bladder was lyhig between the cyst an<l under surface of the liver
being flattened and empty, looking like a dogV tong u>. The gall-'
bladder and cyst w.-re remov<-d and the cystic duct, which was a ./ood
deal elongated, secured in the W(.un.'. The cyst wall ,vas composed of
fibrous tissue and completely retrop.Mitoneal. There were no calculi
present, and there was no pus.

A tubo was pa.ssed to the bottom of the wound and a gauze dIuc
placed l)elow if. o i *.

The patient improved quickly and bile came through the wound, all
attempts later to make it flow in the normal direction being useless.
At the end of October three .attempts caused pain. :inil jaundic,. M!.,wed
On November l.'i the cystic duct was inserted into the second part of
the duodenum and sutured there with a double row of silk sutures. It

(ONTiKXITAL DFVKUTK IM'M ( >K ( ysTlC Dl't T 2s7

was i-asily liiiiir.l to I lie (liKxIrniiiii willioul t.iiM.iii. mii.1 mo .iitriy
iv<|iiiir.l li«iilmv .luiiiii; Ihr n|.».raiiiiii. It win iIi.mikIii \,r.\ i<i ,.|;,r.' a

tlll).> all«l Kiiliz.' pint; <lowil to tlir lii f llliioli. ,s|i,. (,..<Mt,i.. iv,t|r,*

(luiiii>: tin- following' ni«lit aiiii ilinl a tVw lioiirx lator.

Ncciopsy: 'I'Ihti- hail ' t'.'ii ..\t.'iisiv.< liatii(.iiliair<' int.. lli.. ij^flii

Hide nf th.. jil>.l.mi..i,. I.iit Dr. H„x roulil iini tiiKl III.' sour. I th..

I.l.'.^.lilit'. Til.. .lilat...l l.il...ll..-l lii.l l„..u aiia«t..i„osr,l ,M.T.-,|,.||y to
tlir <1ii(mI.miiiiii iimiM..lialrly l.,.y„n.l tl.,. pvl.-ni--. Th.. .•.miiiu.xi .IikI
t.Tiiimal.Ml alH.ut an iii.'h (...lew th.' liv.-r ; l..-y..n.l this it <'..iil.l M.,t I..'
tiaco.l .l..wnwar.lM. Jlxpl.Mv.l rn.tn ih.^ hi! papilla m th.- iIu.mIoiiuiii,
It van lip f.ir an iu.-h anil then <ii.l.-.l. l.iit hlimllv. '!h« iiitiTVi-iiinj;
portion wan n.isMinK. TIi.t,. wa-. nn p.-iitoniti,. hut a .■••iiaiii ainmint
of a.llK'sions iilxiiit the ar.a .>f .ipcialioii.

\ case (,f (livfrticuluiii of the cystic duel i- also fuiiiid in
lilt' St. Tlioinass llospifiil Hi-p.irts t',,r |!hi7.

The IMS,, was that of a (.'ill of IH iimiI.t llif car.' of iji,. lai.. Vr.
('Iiitt..n. She ha.l .•oniplain.-.l of pain an.l ^wi'llinc on the n>;lit si.l,. „f
th.- ah.lonicn f.ir a foiliiiuht. ami had voniiti'.l a .lav or Iw.. l)..for."
uilinissiou. -'-ln'r.' was thi'ii a |)aiiilcss Kwcliini; in 111.' risilit ki.in.y
r.'Kiou. .•x-t.M dinjr sli>;|,tly h.-low tin- Icv.d of the iiinhili.'us and almost
to th.' middle lin.'. 'I'h iiriiif was normal ; ti'iniii'ratiirf. !iH-2 . Kli'vin
days alter a.lmission lumhar incision, paia.'eiu.-sis „f an iiitrap.'ritonoal
c.vst. wilh.lvawal of tw.i an.l a half pints o| oliv.-irrrcii jrlist.-nin:: lltiid
whi.'h ilid not .■ontaiii hilc, althou^rh tlui.l wliiili flow.'d In.ni the

wound later di.l s„. Cyst wall tak.'ii away ; th. hm uas adhe,.ul

to It, t'.i.Tc was fr.M' veiMius lneniorrlia«.> : arr.'sf.-.l hy pliijrs. Th.T.'
were P.uni.'ious facetted calculi in it : a communication with .'ystie
duct at a point where ther.' was a small nippl.'-shap.'.l proje.^'tion.
There was a discharge ..f hilo after removal ..f the iiliiys and sh.-
appear.Ml to be proj;rossinj; satisfactorily until twciii v .lavs afi.'r ..peia-
fioii. when she died from hieinorrhaj;e.

The internal .ipeninfr was close to the nek of th.. «all-lila«l.lri in the
cystic .liict. Th.' Kall-l.la.l.ler contained a IVw .'ahMili : th.' ci.ininon
duct was normal. Th.' haMii.)rrlia<.'e ha.l prol.al.ly come fiom ,i l.ranch
of the portal vein in the jjortal fissure.

Seareli ],as boi-u inado with tlio view of ad-iiii^r somcthinjr
to the soinowliat bar<> rccoi'ds of thcso caso, but iiotliiii.,' lias
been found in surgical literature to give any lielj). ]t is"very
reniarkable that both patients shijuid Jiave reach. •.! the au'cs
attained before .symptoms developed, and that there should
have been no jaundice present in either of them at the time
wlien they came to operation. It is also a curious fact that
in each of them the fatal ending onstied after a ha-morrhafo
the origin of wliieli was quite obscure.

mm

' i

lliii'

ii'i ■

m.

appp:m)ix

I'lIK Ol'KliATlOX ol' (;.'.STIi(>ST(>.MN

As uasliostniiiy riiiiy l)r rcfjiiirc.l :is an i iiu ivciicy oixraliiin
in a ii(j;l<(tt(l case uf irMipha-ical ()l)stiiictinii. | have tii m^iit
it advisalilc 1(» add a lew lines wiiirh niay i iicnuraji'' its pti-
I'orinancc in a patient who appears almost at his last ^rsp. A
man who has heen taking even lliiid nourishment witli dillieidly
hy the month, and is much emaciated, with a dry, haish skin
and sunken eyes, will improve marvellously as a result of tlie
inlnxliietion ot lluid throuijli an opening into the stornaeli.
There st ill appears to '• kind ot prejudice against gast i<)>tomy.
iirstly. l»ecause of the shock which it is sujiposed to cause •
secondly, hecause of the inconvenience which leakage from the
opening may produce.

If a local ana-stlictic is used there is no shock, and the method
of Senn prevents iiakag- of the stomach contents. The
illustration (Kig. 4!S) sh(n,s the normal state of the skin in a
])atient who had gastrostomy performed two years ago [ ,r
impermeable strictuit of the cvsophagus, the result of taking
acid. There is not the slightest al)rasion. whilst the girl is well
nourished and looks healthy, although she is ipiite dependent
for hot food sujiply on the opening. The incision is made
through the left rectus at its outer l)order, and sliould he from
•2 to .'5 inches in length, commencing just below the costal
cartilage. The stomach is easily found, although usually
retracted and cuiall. Traction on the onuntum will bring it
<lown, and a point for the operation is selected. This should
be about midway l)etv.een the greater, and the lesser, curva-
tures, as far as possible from the pylorus. A ru))bei' tube, or
])etter, a Jacques catheter Xo. 12—14. i^< introduced through
an incision large enough to admit it, and fastened in position
by means of a suture which includes all the coats of t he stomach,
A cone which projects into the stomach is made in the following

H i|i|

AnM:Nf)i\

2H«t

luuniu-r A piUM' «tritiu Mitiitc is |ia'>Mil hall .in iiuli away tniiu
thi' tultf cumplftflv (iMiicliii'i it. the tiilic i* (lr|>n*Mil l»\ an

I'm. ^^. — 1. 'rii(> ()]ipiiiii;; t\V(i yiMi-> iiftrr ^.'Mstio^tiiiiiy by .S'liu >
iiirtlii.d, ill 11 irirl m;:ci1 Hi. "J. 'I'hi' Mur of uii o( iiatioii fur
HI lite a)i]iciiili(iti~ niif u'MV aftiT tin- ;,M,-.trii~t.iiiiy.

a.'isistant wJiilst tho Mituro is tied. Two similar sutiirt's are
passfd and tied, the tu))C' litiufr puslu'd in on I'ach occasion.
Tlie stomacli is then Hxi'd to the posterior rectal sheatl- ml

A.A

S90

Al'PKXDIX

llilpllilii:

pt'ritotifuiii of tin- wound. iil»ovt> and hflttw. I»y isiiturf-* wliirh
take ^itdd liiil<l (it it. Suluri'H urt- ihMcrtcd (iii Imtli ■»idc.-<,
sliuttiiiK <>>J till' |M'rit(.ri('al cavity. Tin- sIuniIIi ot tlic ircturt
nhov«« and Im-Iovv the ofx-ninx in .nutiircd and tlicn the Hkin
incision.

The tuhc in l)roiij{ht throuxh tlic dns.siti^ and sccmi'd outride
to the handajjc with a safety-pin. A womlcn pliij; i* inserted
and prevents escape of fluid from the Htoniaeh. The stitch
thronirl; the tuhe rarely holds for nir>re than ten days, hut
unless the clressin^f is eareh'ssly changed or t ..«• patient interferes
the tuhe 'viij retain its position. No ditliculty will he found in
changint <ul)e, liut one of the original size shouM he retair.ed

until the |.,iiient is used to feeding himself and has lost all
apprehension of hurting himself hy passing it. It < iin then he
replaced hy a gastrostomy plug, which is more easily managed
by a patient who wishes to get ahout.

Feeding should l)e commeticed at once, a half a pint of milk
with an ounce of hrandv heing uiven on the tahle. Sultsequent
feeds should he given through the tulie. a snniil glass tunnel
b 'ing u.spd. and there should be no disturbance of the dressing.

INDKX.

AlilMi\u\. iinilr, It'.l

iii,iuiii"> lit. III
WIMIIIil-' lit, IH

AliilninirLiI •'at<i<-tiii|ili i'", IIIT

iiiriKiiili", )>hiiiiilii|!

ol, I
itillurli/.il, I 1:1
iiijiirif'', I

iilti'i' t'tli-rt<. 74
talili' III. :i.'i. :i<i
iiiii'i'li*. iii|iliii<' III, I t
iiiii^riilar ^riiii|i'-. t
»M)iiiiiratiiiii->, I'W*
Hiili, ii'ili'iiia lit. HH
AIki'i'o. a|i|ii'iiitiriilai', l:ti>
lii'|iatli', l:i!)
liriiiTil^tvir, 1 t\
M|l>|>lll<'lilr. 141. I t:t
AliMi«M>. i;i2

riiiici'ali'il. 147
.\ri|iiiifi| ^tiirliin'*. '2'>'\
AcIiiiiirii.Vi'iisis. 1:14
Ai'iiti" aliiliiiiii'ii. !•!»

ilullii"*''. 221
'i|i|M'iiilii-itiH. lit!)
ililatatiiiii III tilt- oliiliiai'ii,
^all^al^<lll •>(. 224
>viii|ilciiii*. 2211
ili>li'ii>iiiii 111 (fall liiaililtT,

2ls
liiiMiMinliauIr )iaiirii'atitis,

214. 2I.S
inti'-t iiial iiliKt nut imi. 11)7
|ianircatitis. 1(17, 2Hi
)iiii>iiiiiiiiiia. 1 1 I
Aiiiti' ililatatiiiii of >tiiiiiarli, 214.

22<>. 22:!
Adhesions. 2."il

Aiucstlit'sia. ailiiiiriistraliiiii nl. II
Aiiastmiiiisis. I'liiltoi'iiil. 24 I

latiTal. 2S'<. 2HI. 2h2
Aiiti'iiiir !:a«tr(i - fiitcriistoiiiy
iiiii-iatiiili- Ui(i

A|l|M'llilirrrtiilliy. Illi'i«iiill for. I2i»
.V|i|irllihritl», anitr. Itl!)

anil kiiliM'v, I l''i
iliauuiisis it, I In
iiirisiiiii (ill, .'1
ii|ifiatiiiii III!', I I'l
f ri'aliiiriit ol, I 111
A|i|)i>iiili<Mtlur alisi'f", l:|i)
A|l|i»'llill\, 2HH

)'in|iy<Miia ol, liDi. I.'i7
vi'i'niitoriiiis. iiitliii'iirc nt
ilisi'a-i', <.)tl

Hll.KKi 11, )M'rliiratiiiiis ol, 227
lliliai.v iiaoau''-, rii|iliiri' ol. ."i!t
Itowfl. iiitussil^ri'litioii III. 2)i)i
2t'i!t
iiivauiliatloii oi, 2li<>
Itiilltl womiiU, 22, 2:1, 2.-|

CwiKi! Ill lai>;i' liouri. 27 I
<'ari-iiiiiiiia. inaliK>iaiir,v ol. 271

of small iiiii'-iiMi'. 2.'i7
rii''iiii| <riii\>tii III niliiii. i:ti

Collin, i-o.loiil j;iinvtli ol, l:t4

iii|itnrr 111. ."ill
I iilii«tiiiny ii|M'i'at Ion, 27ti
( onri'ali'il a'si'i's>i's, 147
( iMi^'i'nital ilivi'it irilliilii lit rvMii'
iliii't. 2H(i. 2H7
st lift III r. 2."i2
* 'ontiisliiiis, 12
Cyst, liydatlil, 2riti
C' ,| i (il jianriiMs. SO

siijipuiation of. 2itS

I)i.\i;niisis of apiii'iiilirilis. I In
l>ia|ilira):iii. Mi|)tiin' of, l.'i
DiuphruiTinatii' lii-rnia, 2()ii

: ah

-^n

W\

•2<i2

INDEX

Divfiticulii, )icil«ivatiini ol, 18S
si^'iiiojdiil, I8t)

Divcrticiiliiiii, <inifr»'iiital. of (•vsti<'
(liiet. 2S(i, 2«7

Ddyt'iTs ('laiii|>s, 24fi

Ihiliic-is in acute alxlonu'ii. 221

Diuiilt'iial hernia, 2.")!»

n'cer. liieinoriliaKe lioni.
2:{it

Dudilcnnni. peiloration nt. I(i7
inptuie of. ts

(iaxlio- jejunal uleei', 172

ulcers, peifoiatioii
of. 172

(;a-itiojejuno>t(>niy. 17.S

• Jastiostoniy operation. 2SH

<ie<tation, ectopic, 2(i|

extia-uteiinc. l!t(i
intrainuial. 2ii2. 2i».")

(Jinilternat's jiyanieiil. 2ii

(HamU, tuberculous. 2ti2

(iunsliot wounils. 2it. 2.'i

K( ToiTr jicstafion. 2iil

Klaterin. 1 2H

Kinliolisni of ine.;enteric vessel

224
Kin]iliyseina, 4(i

Knipyenia of a]»pen(li\, KKi, l."(7
Kntcro-anastoniosis, Kid
i;nteros])asin. 22H

syni|)toins of, 22H
Knterostoniy o])eration, 24'.t
Kxtrauterine jiestation, 1!M>

ru])tuieil, M)H

Kai.loi'i.w tiil)e. infection, 18t)
Fibroids, uterine, 2.">(>
Fibro-niyoniata necrobiosis, 212
Fistula renal, X'.i

urinaiy, 82
'■ Fowler ■■ position. 47. 124

i H KMuHKiiMiK fiom iluodenal

I ulcer, 2:i(i

' llieniorihajio from irasiric ulcers,

2:to

Ilenoclis i)urpura, 2()2
Hepatic abscess. i:{!t
. Hernia. dia|)lna}:niatic. 2))i»
• I dinidenal. 2.")!t

internal. 2.'>!t
Hernial apertures exaniinatioii of,
2.-)2
j protrusions, 2."!.s

I symptoms iind sijjns,

I 2:is

Hyilatid cyst, 2.")»i
Hydro-sal|)inx, 2o:!
Hvpcr])lasf ic, tubercnios s, l:!4
Hysteria, ll:i, 17m

Incisikn for a|)pendicectomv,
120
aii])endicitis. ."i
Influenza, abdominal. 111!
Injuries, abdomimil, I

after elfect-. 74
of the al)domcii. !2
: Internal hernia. 2.')!t

Intestinal obstruction. IIS. 2:!!t
I acute. I()7

j adhesions. 2.")1

I cause unknown, 248

j synii)toms. 218

■ resection. 247

j tuberculosis. 180

Intestine. Kanjrrene of. 24.")
injuries to. 22
I ru])ture of. ;!8

<'Ai.i.-ni,Ai)i)Ki:.

acute distension of, 218
peiforation n\. 171. 227
rupture of. .')8

• iall-sTones, obstruction from. 2.")7,

2.-)8

• lan^'rene. localised, 24()

of intestine, 24r»
treatment of, 24(i
< Jastric crises, 171

ulcer, causation of. 2."! I
ojieration for. 157

)ierfora+ion. I.')4.l.").") _„.,. _,,,

ulcers, l.">2 Intramural j;e^1ation. 2tl2. 20.">

Inemoirhafre from, 2.'i(i Intussusception of bowel. 2»iii —
<iastro-enterostoii:y. Ki."). 2:i2 2(i!»

anterior. o|)eration. ItJIi symptoms of. 2til

'ait'onia of. 2.'>l{. 2.'>4

INDEX

293

Iiitiis-iusci-ptidii THMtnifiit 111.
I II vacillation ot liowfi. 2<)ii

.Ik.mnai. iilcfv, 172, it:!

KiDNKV and aiipi'iiiliritis. II.")
riiptiin- III, (i(). (i", 69

Lakijk bowfl. caiicfv (il. '2']

ijurjio iiifcstiiit".

(ilistnu'tidii <if. 2()!t
syiiij)t()iii>i ol iiialiifiiaiit
firowtli. 272

Lead coli.'. 114. 171

lAvcr duliifss, 4t)

iiiptiirc of. .">4
Jj)cali>t'd sui(|)iii'atioii, i:)ii

.Mac IUhnky o|MTati((ii. l:i.">
Malaria, 114

Mali;;iiaiit jirowTli ol laifjc bowel
sviii|(toms ot. 272
olistriirf ion. 27"
Mfckcrs divciticiiliim. 22!t. 244
MfiiMitcric vessels.

t'liiltolisin of, 224

thionil)o>is of, 224
Mtx'ntcrv. the. 7.S

riijitiiit' of. .")1

san'onia of, 2.').">
Mt'tooiisni, 17
Muscle-;, vijridity of. 4:i
Miiseiilai til>te<. Id

iii:i(litv. 1<)7

N'K( itiisis, fill, 217

" No loop " ojx'iation, 17H

OiisiHi riKiN from j;all-stoiie
2.".7. 2M
intestinal, IIS
nialijjiiant, 271
of laijre inlestine,
2ti!t
< •listriirtions, iWCi
(Edema of al)doiiiiiial wall, HS
Omentum. 7

torsion of. 22'.>. 2:!ii
tuberetilous. 2t>2
!>variaii cyst. su])])uratioii. i:{2

Ovaiiaii (Vsl, .>yiiiptoiii> ol nip
line. 2" 111. 2111
eysts, rupture of. 2it!i

siippiiratiii.'. 2"'.i
tumour,. 2(M>

1'aiss. letlex. 1 17
I'aiirieas. ey>t^ of. Mil

rupture of, ."(2
I'anereatitis. aeiite. Iti7. 2lli
lia'nioriliajrie, 214. 218
operation lor. 21!'. 22'>
raiil.- metliod. 27".t
I'edieie. tor>iiMi of. 2<lt)
I'elvis, exaiiiination of. I(i4
I'ereussion. \alue of. l.")ti
Perforation and leinperaliiii- in

tyiihoid. 1S2
Perforation in lypliiiid. 17'.'
Perforation , f diverlicula. ISS
duodenum. 1)17
irall-hlad.ler. 171
•rastric ulcers. I.")4.

1 .-).-)
j:a s t r o ■ j e i u n a 1

ulcers. 172
small intestine. 17!i
stercoral ulcers. |S(»
stoniacli. 1(17
sill) a<'Ute. lti:i
ulcers. l.')2
Perforations. Stl

of liileduct. 227
jrallliladder. 227
I'ericolitis sinistra. I'.Ht
' Perijrastric al)>ce,s. 141
Peri.-ij;moiditis. 147
I'eritoneiim and typhoid. 18.1
treatment of. 1(11
t uherculoiis. 2<)2
Peritonism. .'iS. 48. !»8, KM. 17'.t.

2l»7. 2:!!t, 244. 2(11
Peritonitis. 8)1

pneumococcal, !Hi
]iuer])eral. I'.t7
streptococcal, !)2
symptoms, of, 8(1
toxic, 24)1
tuberculous. !l.")
Pneumococcal peiilonitis. Ilii
Pneumonia. 171

acute. 1 1 1
Pouches. 2.Vt
Protrusions, 2i»
PiKM'peral ](eritoiiii i>. 1(17
Pulse-.ate, 1(12

294

INDEX

Pyosalpinx, 133, 196
rupture, of, 198
tuberoulouK, 150

Kectup) abdoiiiiniH muscle, 6, 8

Reflex pains, 1 17

Renal fisttila, 83

Rej*ection of intestine, 247

Rupture of biliary passages, 59
duodenum, 48
gall-bladder, 58
intestine, 38
kidney. 66, 67, 69
large bowel, 50
liver, 54
mesentery, 51
ovarian cyst, symptoms
of, 209, 210
cysts, 209
pancreas, 52 ^

pvosalpinx, 198
spleen, 60, 63
urinary bladder, 70, 71

Rupture, symptoms of, 39

Ruptured extia-uterine gestation,
168

Ruj»tures, cause-; of, 37

Salpin<;itis, 190

Sarcoma of intestine, 253, 254

mesentery, 255
Sigmoifl, tuberculous, 187
volvulus of, 284
.Sigmoidiil diverticula, 189
Simple stricture. 252
Small bowel, tuberculous ulcer of,
186
intestine, carcinoma of, 257
perforation, 179
Spleen, rupture of. 60, 63
Sterocral ulcers, 190, 193

perforation of, 189
Stomach, acute dilatation of, 214,
220, 223
causation of acute dila-
tation, 224
perforation of, 167
strangulation of, 236
svmptoms of acute dila-
" tation, 220
wounds. 24
Strangulation by bands, 250
of stomach, 236

Streptococcal peritonitis, 92
Stricture, congenital, 252

simple, 252
Strictures, acquired, 253
Subphrenic abscess, 141, 143

operation, 146
Suppurating ovarian cysts, 209
Suppuration, localised, 130
of cysts, 208
ovarian cyst, 132
Suppurations, abdominal, 139
Symptoms, 18, 21

Tabes Dorgalis, 114
Temperature, rise of, 44
Thrombosis of mesenteric vessels,

224
Torsion of omentum, 229, 230

pedicle, 206
Toxaemia, 98, 122, 129
Toxic peritonitis, 240
Tubal abortion, 205
Tuberculosis, hyperplastic, 134

intestinal, 186
Tuberculous glands, 262

omentum, 262
peritoneum, 262
peritonitis, 95
pyosalpinx, 1.50
sigmoid, 187
ulcer, small bowel,
186
Tumours of ovaries, 206
uterus, 206
Typhoid and peritoneum, 185
fever, 112, 179
perforation in, 179

and tempera-
ture, 182

Ulcers, gastric. 152

perforation of, 152
stercoral. 190, 193
Urinary bladder, operation, 73

ruptureof, 70, 71
fistula, 82
Uterine fibroid, sub-peritoneal,
211
fibroids, 256
tumours, 206
Uterus, rupture of, :! 1 , 32

Viscera, rupture of, 34
Volvulus, 245, 283

INDEX

VolvnluH of HiKiiioiil, 284
Vomiting, 207

Wounds of th« aljiloiuon, 18
blailder, 2it, W
(liu|>)ira);iii, 2.')

Wounds of Kall-I>lii(l<l<'r,
kidney, 27
livfr, 2.">
pleura, 2.">
portal vc-isfl
renal |)elvi-i.
ureter, 28

295

2t)

BBADHtKy, AIJNKW, A

I.D.. l-inSIKHS, LOKD 'N ANU TONRKIDOK.